The Honolulu Department of Emergency Services has identified its top 10 clients and found that the most frequent 911 caller used an ambulance 142 times in a year, a startling figure that is prompting a push to guide people to more appropriate care.

"We definitely want people to call 911 in an emergency," said Dr. James Ireland, director of the Hono-lulu Emergency Services Department. "But when it rises to the level of 50, 100 or more calls per year, that indicates that we need other avenues of assistance for these individuals to help them with their medical or psychological needs.

"So we’re developing a program to reach out to them. We think it will not only help them but also save a lot of money."

The price of each ambulance trip is $795, and visits to hospital emergency rooms run from several hundred to thousands of dollars. So costs quickly get out of hand when patients rely on 911 as their main means of getting medical care. Most of the top 10 ambulance users had a government form of insurance, such as Medicare or Medicaid, and taxpayers wind up with the bill.

Eight of the top 10 were homeless people, according to the city’s 2011 ambulance records. Six of the 10 had alcoholism. One had a diagnosed mental illness. About half of the calls came from the patients themselves, while the other half were from concerned citizens.

The most frequent user on the list, a 55-year-old homeless man who suffered from recurrent bouts of asthma and other medical problems, died last year. He used the ambulance 142 times in 2010, the last full year of his life. Others on the list clocked in with 91 calls, 75 calls and 50 calls in 2011. The average among the top 10 was 52 ambulance trips.

"What we’re looking at is how we can identify and help these individuals get the care they need without always resorting to 911," Ireland said. "We’re focusing on frequent EMS users and what is the root cause. Is it access to care? They don’t have a doctor? They don’t have the medications?"

"Our goal is directed and intensive focus on any individual using EMS more than 15 times a year," he added. "These people truly need our help. This will be a collaborative effort between the City and County Emergency Medical Services and multiple government and private health care and social service providers."

The department hopes to get a pilot project rolling by the end of next month, he said. EMS District Chief Kelly Yamamoto led the initiative to collect information on top users.

Asked whether emergency workers could turn down people who overuse 911, Ireland said that is not an option. "If someone requests transport and there’s a medical need," he said, "we do that."

Lori Tsuhako, administrator of state homeless programs for the Department of Human Services, said a working group at the state Interagency Council on Homelessness also is looking at "the burden that a real small number of people put on the larger system" and will collaborate with Ireland.

"In the long run it would be much more efficient and economical for us to be providing some housing and wraparound service to these folks," Tsuhako said. "Eventually their use of medical and mental health services goes down when they are stabilized. It makes sense."

A substantial number of 911 calls come from concerned citizens who encounter people in dire straits on the street. Another way to help is to call the Homeless Help Line at 791-9359 or send an email to homelesshelp@waikikihc.org, Tsuhako noted. The Homeless Help Line is operated by the Waikiki Health Center Care-A-Van Program, which will deploy an outreach team as soon as possible.

Senate Health Committee Chairman Josh Green has seen the trend toward overuse of emergency services firsthand in his work as a physician, and it extends far beyond people who are homeless.

"In my life as an ER doctor, we are seeing many of the same patients repeatedly coming to the ER," Green said. "They need better access to care from primary care doctors and urgent care doctors."

In a report to the Hawaii Pacific Gerontological Society last week, Green said that nearly 50 percent of all emergency visits in Hawaii should be handled in a primary care setting. But the state’s shortage of physicians and "virtually no access" to primary care for some patient populations leads to overuse of emergency rooms, he said.

"This inappropriate use of the state’s emergency departments results in disjointed care for patients at a premium expense," he wrote. "Specifically, ER physicians treat patients that they don’t know, at approximately 10 times the cost had they been treated by a primary care physician."

He cited examples of emergency room bills and diagnoses including $1,616 for abdominal pain at the Queen’s Medical Center, $1,357 for "dizziness and giddiness" at Kaiser Permanente, and $1,037 for "fever unknown origin" at Kapiolani Medical Center. Those cases involved basic health matters that posed no critical threat to the patient, he said.

"There appears to be a real potential to cut health care expenses dramatically if we expand alternatives to ER care for basic health matters or if we provide real incentives for patients to avoid the ER when other options are available," Green said.

Green called for immediate implementation of a program to divert people from emergency rooms to primary care providers with extended hours and to urgent-care clinics. In the longer term, the shortage of physicians in the islands must be addressed, he said.

Green is the executive medical director of the Hawaii Independent Physicians Association, which represents 800 doctors in the state, about 40 percent of whom are in primary care and the rest specialists. A recent survey of their billing records for 2011 found major disparities in costs, he said.

"We found that 3.6 percent of our patients on Medicaid accounted for 61 percent of all Medicaid costs," Green said. "Often a very small number of individuals consume a very large amount of the health care expenditures. If we can do better in getting them care in the right places, we will have a much improved health care system and have other monies to invest."