The 80-20 Rule and Emergency Health Care

Have you ever heard of the Pareto Principle? It is the interesting observation that not everything is proportional. The first time I heard it was in a seminar on church growth from John Maxwell, a Wesleyan pastor. It was back in the late 1980s before Rev. Maxwell wrote a bunch of books and became a famous author. At that time, he was listened to because his church was a fast growing megachurch.

In the church context, it was put thus: 80% of the work needed to be done in the church is done by 20% of the people who attend. (Here is a link with more detail on the rule--and there's lots more about it--just google 80 20 principle.) I got to thinking about this principle due to these blog posts from ckemtp and happy medic about "frequent fliers"--people who use emergency services on a very frequent basis, either requesting emergent aid for non emergent situations, or failing on a repetitive basis to do the simple things that would keep them from needing emergent aid. The posts got me to thinking about frequent fliers I have known. Ask any paramedic, EMT, or ED nurse, they could give you names of people they see at least once per week if not more.

The majority of people may go the ED less than ten times in their lifetimes. Some people will get a chronic condition that may cause them to appear more often, but they manage their condition properly, and at most, require an ED visit once every three months. That's 80% of the population. The number of people who become "frequent fliers" is quite small.

Maybe 20%.

But what does this 20% cost the health care system?

This 20% that should take their meds, keep their appointments, quit drugs and alcohol, and stop fighting; this 20% that could keep themselves healthy and out of the ED for quite a bit less money than each of their ED visits--this 20% hurts our system badly. 80% of the costs? Maybe, maybe not--but definitely costs higher than their proportion of the population.

And, unfortunately, some of these people are shall we say?--hard to love. Some are intoxicated and combative. Some have unpleasant prickly personalities. Heck, some of them need to take a friggin' bath and/or change their clothes every so often! So in addition to the financial cost, they cost caregivers important emotional capital; the empathy needed to do the job of caring for others well. This 20% takes time, strength, empathy and resources out of the system disproportionate to their number.

What to do? Good question. Happy Medic covered the failures very well. Unfortunately, emergency services cannot "fire" a patient. We can't say, "Sorry, not bringing the ambulance over to your house."; "Sorry, not letting you in the ED tonight."--it's against the law. And how much time to spend on each person as a society, trying to "make them change"--because it is their choices that make them frequent fliers.

Like Happy Medic (and I strongly urge you read the post), I don't have any easy solutions. A few ideas: Change insurance so that patients are somehow responsible for ED visits not medically indicated. Teach, cajole and urge until the caregiver is blue in the face. Give very specific instructions for alternatives to calling 911 and/or going to the ED. Increase primary care provider availability. Remove the Sword of Damocles of lawsuits from over the heads of ED providers trying to make decisions about frequent fliers.

Bottom line, it comes down to personal responsibility and choice on the part of the patient. Each of the above ideas might take a percentage point or two off of the 20% and they all should be part of health care reform. If we can get the 20% down to 15% or 12%, it would save a bunch of money and resources. But because humans are finite and sinful, there will always be people making bad choices, always. Alas, frequent fliers, like the poor, will always be with us.

That has implications for the caregiver, especially those health care workers who call Jesus Christ their Savior and endeavor to follow Him. Jesus loved and touched the leper, told his disciples to forgive "seventy times seven", and hung out with tax collectors and "sinners". It's a high standard He set, doing all this loving and forgiving. The only way I have a chance to even get near this standard is to allow Him to fill me with His love and power through the Holy Spirit. This is the way I can persevere through the difficult times and remain empathic and caring. (The health care worker who wishes to stay in the game must remember to care for and restore their own body, mind and spirit; there must be resources in you to give you strength as you care for others. That goes for everybody, not just Christians.) The only chance some of the "frequent fliers" have for real change is through the power of that same Holy Spirit.

Because at bottom, this is a spiritual issue as much as it is a health care issue.