Frequent emergency department visitors: the end of inappropriateness.

In 1992, a 4-month-old boy with fever and irritability was taken by his parents to the local emergency department (ED) late at night. The emergency physician on duty diagnosed otitis media and prescribed antibiotics and analgesics, and the child recovered without incident. His parents, both physicians, spent the next year in a losing battle with the insurance company, which denied payment because of the “inappropriateness” of the visit. The insurance company claimed that because the baby’s fever was less than 103°, the visit was unnecessary. The boy’s father (and author of this editorial) was impressed with the insurer’s creativity in denying the claim. Incidents such as this sparked a new focus in the 1990s on examining visit appropriateness and crowding as key policy issues in emergency medicine. ED visit volume grew sharply during the decade, along with denials of payment by managed care organizations, leading in part to the adoption of the prudent layperson standard at the federal and state levels. The earliest reports of ED crowding cited myriad causes, including the inability to move admitted patients upstairs to inpatient wards and, in urban areas, a growing number of mentally ill and substance-abusing patients. These disparate causes would later be explicated nicely in the input-throughputoutput conceptual model of crowding. In 1993, the General Accounting Office (now known as the Government Accountability Office) issued an influential report that asserted the growth in ED use was largely due to uninsured, elderly, and seriously ill patients. The report also noted that 43% of ED patients had nonurgent conditions, many of which could have been treated elsewhere in the community. This latter statistic received considerable attention and became the basis for much of the conversation about “inappropriate” ED use. More recent data showing that most of the growth in ED visit volume came from patients insured privately or by Medicare did not quell the discussions about “inappropriate” ED visits. Subsequent policy debates about ED crowding have been muddied by the confusion of separate but related phenomena and lack of clear definitions. These include: