It's people who don't have a relationship with a primary care physician who are returning to the hospital's emergency department time and time again, said Tony Houston with St. Mary's Health Center (SMHC).
In health care, these individuals are sometimes termed "frequent fliers."
"It can be a myriad of reasons why folks don't have access to primary care, access to what we would call health maintenance options," said Houston, executive vice president and chief operating officer at SMHC. "I think economics is probably the main driver, but it's not the only driver."
Frequent fliers among Missouri's Medicaid population will be a topic of discussion at the Missouri Legislature's Interim Committee on Medicaid Transformation's hearing Tuesday.
Daniel Landon, senior vice president of Governmental Relations with the Missouri Hospital Association (MHA), said at a Medicaid hearing last week that in 2012, 5 percent of Missouri's Medicaid enrollees who used hospitals generated 52.3 percent of the hospitals' expenses.
"We need to find those 5 percent and manage them well," Landon said. "Our recommendation is to really focus on the higher cost utilizers."
Houston said many factors lie within these statistics, but they may stem from the population not having that primary care relationship, therefore being sicker.
"I think we do find there's a prevalence of chronic disease that isn't well-managed, but it's not necessarily well-managed with folks that have insurance either," Houston said. "It depends on how folks are engaging their own health providers and actually adhering to the advice and regimen they're given."
Houston said the state's opportunity to expand Medicaid to 300,000 additional Missourians would have helped alleviate the misuse of the emergency department.
"It really is about access, about appropriately accessing care, and building those relationships with folks that can help you with managing chronic disease or lifestyle choices and changes," he said. "Where if you have that ongoing relationship, your episodes are probably farther apart and you don't have to access the emergency department other than for true emergencies or when there's no other place to go."
He said he believes the intent of President Barack Obama's health care law and the push to get folks covered was to help with health care access in the appropriate setting.
Both local hospitals - SMHC and Capital Region Medical Center (CRMC) - have discussed how they can better provide care in the appropriate setting, citing Heartland Regional Medical Center in St. Joseph as one hospital that has found success. The hospital's emergency department has found a model that allows them to direct lower-risk, non-emergent cases to primary care physicians and clinics.
Tawny Sandifer, vice president of Patient Care Services with CRMC, said during a discussion earlier this year that the key is identifying those non-emergent cases and navigating them away from the use of the emergency department.
"It's hard at times," she said.
Landon said with the state's discussion of Medicaid, MHA believes the focus should continue to be on these highest cost utilizers.
"We need to find them and manage them well," he said.