At the Concord Hospital Family Health Center, a primary care practice in Concord that treats a large number of poor and uninsured patients, a simple change in scheduling policy has yielded a dramatic change in how often its patients visit the emergency room.

According to director Marie Wawrzyniak, after the practice shifted from the traditional model to one where many appointments are scheduled the same day and most are planned less than two weeks out, center patients used the emergency department 40 percent less than before.

"We're proud of the decrease in visits by our patients," Wawrzyniak said. "And we think it's because they can get in to see us easier now."

That case study may be food for thought for state officials as they consider a small subset of patients who are costing the state a lot of money in emergency room visits. A study released by the state Department of Health and Human Services this week found that 5,800 patients - about 5 percent of patients using Medicaid - cost $7.8 million from frequent visits to emergency rooms.

The study looked at this group and compared it with Medicaid patients who used the emergency department less often - fewer than four times a year. To many health care experts, the results were surprising.

For years, state officials, hospitals and health care policy leaders have focused on building a network of primary care doctors so patients could get more preventive care and disease management in a doctors' office instead of the emergency department. Emergency room visits are more expensive than office visits and they're unlikely to help patients manage chronic health problems, since the doctors and patients don't know each other and there's little follow-up.

Several parts of the state still suffer from shortages of primary care doctors, but the study found that frequent-flier patients who visited the emergency room most often were not those without doctors. In fact, they were twice as likely to have seen a primary care doctor in the last year.

"The normal story with this is, 'Oh, it's access to care,' " said Andrew Chalsma, an administrator at the health department who helped prepare the state report. "But this kind of proves it's not. It's not access to care - at least in the way that people think about it."

The problem may be more complex and more challenging for policy makers to address, doctors and state officials said. Patients qualify for the Medicaid program if they're poor or suffer from permanent disability, making them much sicker than the general population and more likely to have other obstacles to care, like difficulty with transportation or poor nutrition.

"If you have a socioeconomic disadvantage and you're really sick, it's like a one-two punch," said Dr. Christopher Fore, an attending physician at the Concord Hospital emergency department.

Henry Lipman, the CFO at LRGHealthcare, said he hired students this summer to do an experiment. He asked them to call around to local primary care practices and try to get an appointment. The students were told to pretend that they had different kinds of insurance - commercial coverage, Medicare, Medicaid or no insurance at all. He said that most patients were able to get in with a doctor, regardless of their ability to pay. But the appointments were often far in the future or at times that the students said they didn't want.

"It doesn't seem like it's the access, it's the timeliness of the access as well, and the underlying conditions," Lipman said.

Dr. Paul Racicot, the chief of the emergency department at Franklin Regional Hospital, said that it makes sense that very sick or very poor patients sometimes choose the emergency department when they can't get a quick appointment. In his years working in the emergency room, he's been amazed at the number of patients who walk in off the street or need rides to the hospital. Patients without their own transportation, he said, might only have certain times they can seek medical attention.

Those patients, he said, might choose a doctor's office if they could get a same-day appointment.

Dr. Doris Lutz, the medical director of the state's Medicaid program and an emergency room physician herself, said that Family Health Center model is appealing. She said the state is working to build a larger pilot program of medical practices that offer quick appointments.

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