Frequent Fliers

One reason why healthcare costs in the U.S. are spiraling out of control involves frequent fliers in the emergency department. I don't have any numbers or statistics, only a gut feeling borne of experiences in the emergency department, wards, and operating rooms. There is some small population of patients who utilize healthcare resources far more than anyone else, and furthermore, they use costly venues of healthcare delivery. These patients have chronic pain or uncontrolled psychiatric illness or social problems or addiction. They come repeatedly to the emergency department but aren't otherwise followed by a primary care physician. The E.D. places a band-aid on the problem, encourages them to get insurance and find a doctor, and sends them out. But we already know that they'll soon be back.

These repeat customers drain the system of resources. They drive up healthcare costs by hopping from one emergency department to another, getting a battery of tests, occasionally being admitted, and being sent home (or to the street) without a solid plan of care. Their diseases could be controlled in the right circumstance, but they have no incentive to do so and instead become frequent fliers on an episodic basis. Even some patients with chronic pain prefer to come into the emergency department to get boluses of IV opiates rather than control their disease long-term with a pain management plan.

I don't think this is either appropriate or sustainable. However, our solutions have not worked. There have been many initiatives to get patients like this a primary care doctor or medications or an urgent care clinic to visit, but the problem is still persistent. I think the only way to make headway on this problem is to get buy-in from the patients. We need to contract with them; if they come in with chronic pain complaints and have no other etiology for pain, then they only get pain medications they could have taken at home. If they frequently have psychiatric crises, they do not need the battery of laboratory tests we normally send (we usually send a complete blood count, electrolytes, liver function tests, HIV screen, thyroid function tests, urinalysis, urine toxicology, and EKG prior to admitting the patient to psychiatry). We find some incentive for patients if they are sent to the emergency department by an urgent care clinic or their primary physician. We need to search for solutions for this problem, especially as resources get more and more limited.