Are You Sending Patients Home? You Should Be.


Emergency physicians have historically been ambivalent about inappropriate ED utilization. We deplore it but are reluctant to address it because we believe that there may be no alternative for these patients, that excessive risk or the threat of an EMTALA violation are prohibitive, or that it may cost us practice revenue. But failing to address an issue of critical importance to our hospital customer is the first step on the path toward losing the contract.

Emergency physicians must take a leading role in the fight against inappropriate utilization of the emergency department  


Emergency physicians have historically been ambivalent about inappropriate ED utilization. We deplore it but are reluctant to address it because we believe that there may be no alternative for these patients, that excessive risk or the threat of an EMTALA violation are prohibitive, or that it may cost us practice revenue. But failing to address an issue of critical importance to our hospital customer is the first step on the path toward losing the contract. We should be proactively leading the effort to deal with this problem rather than being perceived as reluctant participants.

The emergency physician group may consider these kinds of patients a relatively small problem since they typically represent minimal professional revenue. However, the costs are much greater on the hospital side. With a fairly constant industry-wide 1:3 ratio between ED professional and facility charges, a $1 physician group loss translates into a $3 hospital loss. This fact, coupled with the dramatic increase in imaging and other testing costs, generates a growing uncollectable that the hospital would like to see its emergency physician group take seriously. As payment re-configuration moves to global prepayment within the construct of an Accountable Care Organization failing to manage emergency physician ancillary utilization, especially as it relates to imaging, will further exacerbate this problem.

As a charter faculty member of ACEP’s ED Director’s Academy I have participated in the Phase I panel discussion titled “Keeping Your Contract” twice a year for the past six years. Invariably, one or another faculty panel member will offer the advice that to keep your contract you should be thinking ahead of your hospital administrator and anticipating his or her needs. There is probably no better issue to illustrate this than the issue of inappropriate ED utilization, which falls much more in the purview of emergency physicians than does inpatient re-admission reduction. And yet, in spite of being fully aware of the problem, most of us are failing to act.


The Kaiser Health Plan of Colorado has estimated that 20% of its 72,000 ED visits per year are “unnecessary.” This percentage may be higher in areas without Kaiser’s comprehensive approach to primary patient care and care coordination. Others argue that the percentage of unnecessary visits may be lower than this since 88% of ED visits are identified in most surveys as “urgent” in nature. Regardless of the exact percentage, there is little doubt that inappropriate ED use exists and that overall health system costs could be reduced by re-directing some of these patients to less costly sources of care.

Inappropriate ED utilization is most evident among those we often label as “frequent flyers.” A July 2010 e-survey by the Healthcare Intelligence Network ( found that the majority of these patients could be grouped into one of four main categories: chemical dependence, pain management, medication non-adherence and behavioral health. There are discrete strategies to deal with each of these, such as enforcing pain management contracts or improving the referral coordination to longitudinal care providers. The problem is that rarely does anyone see it as their job to manage these things. To make a difference, an intervention must be organized in advance, well documented and consistently applied. And all of these things require leadership, which has to come from the physician group.

Many of those utilizing the ED inappropriately are unaware of the alternatives available to them. They are often seeking either the convenience of not having to schedule an appointment or of obtaining care without being required to pay anything for it. These patients are unlikely to be re-directed to an urgent care or a physician’s office alternative without also having a disincentive to the inappropriate ED utilization. Any disincentive(s) to inappropriate ED utilization must follow, rather than precede, the completion of a Medical Screening Examination (MSE). Once it is definitively determined and documented that no emergency medical condition exists, a variety of strategies can be employed, such as:

A separate waiting room for those inappropriately using the ED and who are unwilling or unable to make a time of service payment toward the cost of their care, coupled with a policy which says, in effect, “we will get to you when we can.”


A “triage out” program, which requires that non-emergent patients be referred for definitive care unless they are willing/able to make a time of service payment toward the cost of their care. Those operating such programs say that very few patients actually chose to be referred out but that the fact that patient’s are asked to pay something at the time of service gets passed by word-of-mouth in the community and that this provides an incentive for patients to seek more appropriate sources of care.

A dedicated social worker or case manager in the ED to help patients to explore primary care ‘medical home’ options such as a Federally Qualified Health Center that receives supplemental Medicaid reimbursement and is required to accept all patients on a sliding scale fee basis.

There are an increasing number of transition management software products available that can automatically identify patients in real time who may be inappropriately using the ED and then support their placement into a medical home. Transitioning these patients to a more appropriate care setting serves to relieve ED crowding and reduce the hospital’s ED uncollectables. By taking charge of this issue ourselves we can be perceived as our hospital’s committed partner, proactively addressing one of their chief concerns, rather than being perceived as a reluctant follower.

Dr. Hellstern is an independent hospital-based practice management consultant and Chief Medical Officer for Loopback Analytics in Dallas.



  1. Charles Krin, DO on

    A couple of points that need to be considered in any method utilizing ‘triage out’ or referral options:

    First, [b]Every[/b] facility in a geographic region must agree on this sort of implementation [b]and[/b] agree to assist with the referral options, including providing the facilities and staff needed for appropriate outpatient care. Otherwise, A: any ED in the region which does [b]not[/b] implement the referral option will be swamped with migrating patients and B: the limited number of primary care providers (both Physician and MLP staffed) will be unable to handle the influx of patients, resulting in even longer waits for care, and temptation to return to the ED.

    Second, Third Party Payors, including CMS, must rationalize their payment schedules to improve the incentives to Physicians and MLPs in Primary Care. The average incentive package I have seen over the past years runs about $150,000 for a primary care practice, including 4 clinical days a week, and often 1:4 weekend call. I averaged about 80 hours per week (around 300 per month) working in those conditions, albeit without hospitalist coverage for my inpatients. The average ED practice offer I see runs more on the order of $300,000 for 12 shifts or 144 hours per month, or around half the time in the facility and no call. Somehow, I don’t think that the EM groups would pay this much if they weren’t making a profit on top of it.

    Third: Hospital administrators [b]must[/b] be prepared to accept significant hits on their Press Gayne scores when the implimentation starts, and continuing until all of the inappropriate users are settled into their new clinics and patterns. I suspect that this will be an even bigger problem than the cost of providing the needed primary care facilities.

    I have maintained for years that the FM and EM communities MUST ally to preserve the ability of both groups of physicians to function under the increasing financial strictures that the medical community is facing.


  2. Mysticheadlice on

    There seems to be an implication here that misuse of the ER should only be discouraged if the patient is unable to pay. Nothing could be further from the truth. ER abuse/overuse is independent of this.
    Anyone who suggests that “88%” of ER patients have an “urgent” problem isn’t working anywhere I have ever worked in the last 31 years, I would suggest 60% at most have actual urgent problems.

  3. Thanks.
    Yet another consultant espousing from an ivory tower.
    We’ve allowed this specialty to become everything to everyone, essentially becoming the janitors for those ever-dwindling primary care physicians and overpriced specialists which have turned specialty/surgical care into hours bankers would envy. “Referral coordination to longitudinal care providers for frequent flyers?” Are you kidding? Sounds great in theory, but does little to change behaviors.

    How about this – (a) have the hospital administration “collaborate” by “incentivizing” PCPs/specialists as a condition of privileges/staff membership to accept their responsibilities in managing the chronic complaints of identified “frequent flyers.” Track those offices who refer patients to the ED for “acute diagnostic workups” that they could have done until they found their wallet biopsy was negative.
    (b) no PG surveys to those frequent flyers.

  4. In my experience of more than two decades, the actual ED nonurgent is more like 50%. In fact, in most small ED’s in rural areas, the hospital could close the ED at midnight and not open until 0600, and patient care would not suffer. True emergencies at night, as defined by imminent loss of life or limb, are quite rare. Drunks, druggies, and new mothers seem to populate late night.

  5. I agree with all the others- the ER has become the dumping ground for everything- from lazy PCP’s to Medicaid dumps. No administrator will risk the fallout from this and the very few times I’ve seen it done, the decision is reversed within 2 days max. It’s sad that the highlight of my almost 30 years in the ER was hearing a patient with yet another toothache, when being told we were screening him out to pay first, yelled ” When did you start this sh1t !!!!”.
    This is also why I am finally getting out of the ER and will just have a private practice- no Press – Gainey’s and if I’m going to see the same patients everyday for minor problems, I’ll at least do it 8-5, Monday thru Friday.
    And it’s better to be the dumper than dumpee.

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