Mental Health and High Use of Emergency Departments

April 06, 2017 10:55 AM | Sally Winkelman (Administrator)

April 4, Treatment Advocacy Center, Research Weekly

Mental health conditions increase the likelihood that adults who visit hospital emergency departments (ED) will become frequent utilizers, according to a new analysis of ED use by high-need, high-cost patients who repeatedly use healthcare services.

In 2014, ED super utilizers made up no more than 6% of ED patients by age or payer category but generated  up to 26% of all ED visits in 13 states, according to a statistical brief published by the Agency for Healthcare Research and Quality (AHRQ). 

Mental health symptoms increased the likelihood a patient would be a super utilizer.* 

The Role of Mental Health in ED Super Utilization

The authors of "Characteristics of emergency department visits for super-utilizers by payer, 2014" maintain that identifying the characteristics of ED super utilizers is essential to addressing their high use of the ED services. 

"Over the last several years, health care stakeholders have paid increasing attention to issues specific to high-need, high-cost patients who constitute a very small percentage of the population but account for a disproportionally high amount of health care utilization," H. Joanna Jiang and colleagues say. "These patients, dubbed super-utilizers, represent a broad spectrum of demographic and clinical characteristics and socioeconomic conditions. 

"Programs designed to improve care for super-utilizers need to be tailored to the specific needs of the different subgroups of these patients. As part of this effort, it is important to examine differences in utilization patterns among different types of super-utilizers, in comparison to national benchmarks." 

For the statistical brief, AHRQ examined 2014 ED data from 13 geographically dispersed states that are home to about 28% of the US population. They compared ED use patterns by payer: Medicare for recipients 65 years and older, Medicare for recipients 1 to 64 years old, Medicaid, private insurance. 


Among the findings: 

  • Mental health ED visits were more common for super-utilizers than for other patients regardless of payer. Among super utilizers insured by Medicaid, for example, 7% of ED visits were for mental health complaints, double the rate for individuals who were not making high use of the ED. Super utilizers insured by Medicare, regardless of age, and by private insurers also were more likely than other patients to visit the ED with mental illness symptoms. 
  • Super utilizers as defined by AHRQ made an average of four to five more ED visits per year than other patients. The 6.1% of Medicare patients 1-64 years old who were super utilizers, for example, made 26.2% of all ED visits. Similar patterns were seen for older Medicare, privately insured and Medicaid patients. 
  • Super utilizers accounted for an outsized proportion of ED costs. For example, while only about 4% of ED users insured by Medicaid were super utilizers, these patients accounted for nearly 20% of total ED charges to Medicaid.  
  • Among the payer groups, Medicare and Medicaid patients 1-64 years old were the most likely to be super utilizers. Approximately one in 10 patients in this age group were super utilizers. In contrast, approximately one in 20 patients who were privately insured or 65 years old and insured by Medicare were classified as super utilizers. 

The most common reasons for super utilizers visiting the ED were medical (e.g., chest pain, superficial injury, abdominal pain and other physical conditions). Patients with three or more chronic conditions were more prevalent among the super-utilizer population than among other ED visitors.

The role of mental illness on super utilization in America's EDs is one of several issues the Treatment Advocacy Center examines in its upcoming study, A Crisis in Search of Data: The Revolving Door of Serious Mental Illness in Super Utilization, scheduled for release April 18.

*AHRQ defines ED super utilizers as private patients age 1-64 years who make four or more ED visits in a year or Medicaid/Medicare patients who make six or more visits.