The passage of the Patient Protection and Affordable Care Act (Affordable Care Act or ACA) has put a spotlight on the use of the nation’s emergency departments (EDs). There is a public perception that the uninsured are heavy and frequent users of EDs, and expanding insurance coverage under the ACA will relieve ED crowding. Analyses of who uses EDs and why tell a more complex story, including the possibility that health reform will increase ED waits and crowding.1 As more individuals gain health insurance coverage, demand is likely to outpace physicians’ busy office schedules; many are likely to turn to the ED for care.
The ACA includes a substantial Medicaid expansion and subsidies to increase insurance coverage. These initiatives are projected to insure 32 million individuals. When similar health reforms were passed in 2006 in Massachusetts, officials hoped that expanded coverage would improve health and decrease the burden on EDs. Recently released state data, however, shows the opposite—ED visits increased nine percent in Massachusetts between 2004 and 2008.2 State officials pointed to primary care access problems as the source of the increase.
If Massachusetts can be considered a predictor for what might occur nationally under health reform, then ED crowding may persist and worsen with an influx of newly insured individuals. The need to identify the systemic problems causing ED crowding will be important to ensure that EDs can continue to function and provide the timely care that is critical during medical emergencies.
Barriers to Access and Capacity Constraints
In 1986 Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA). This law requires Medicare-participating hospitals to provide a medical screening exam on all patients that come to the ED and stabilize those experiencing medical emergencies, regardless of ability to pay.3 This law grants individuals a legal right to emergency care in an environment where many patients lack access to regular physician appointments. The current recession has made access even more difficult. In 2009, the Kaiser Commission on Medicaid and the Uninsured conducted a series of interviews with emergency department heads and found that ED capacity was near the breaking point. Interviewees pointed to several economic pressures that were contributing to crowding, including rising numbers of uninsured individuals and the inability of the insured to afford rising out-of-pocket costs.4 Although 2007 data from the National Center for Health Statistics shows that the uninsured were no more likely to have an ED visit than insured patients, those with Medicaid were more likely to have had multiple ED visits in a 12-month period than both the uninsured and the privately insured. Additionally, as family income increased, the likelihood of having an ED visit decreased.5 This data suggests that low-income populations rely on the ED for care and as the recession has affected more individuals, the pressure on EDs has increased.
Usual Source of Care
In addition to economic pressures, an aging population coupled with increasing numbers of patients with chronic illnesses strains the health care system and sends patients to the ED.6 Individuals without a usual source of care who have one ambulatory visit during the year are more likely to visit an ED than those with a usual source of care, particularly if they are low-income.7
Patients experiencing acute illness are also likely to visit the ED due to barriers to primary care access. A recent study found that less than half of all acute care visits in the United States are made to patients’ personal physicians. Emergency physicians handle a quarter of all acute care encounters and more than half of such encounters for uninsured patients. The authors point to several possible reasons for lack of primary care physician availability including the constraints of busy schedules that preclude same-day scheduling, short time for seeing patients during appointments, and the low number of primary care practices that see patients after hours.8
EDs have responded to these primary care constraints and many are offering preventative services. A study from Stanford University Medical School found that 90 percent of EDs nationwide offer preventative care services. These results illustrate the conflict that EDs face of needing to address underlying health problems that result in repeat visits while also preserving their mission of providing acute care.9 EDs in safety net hospitals feel this pressure acutely. As their facilities become more crowded, many safety net hospitals are working with their communities to increase outpatient access for the vulnerable populations that they serve. Providing primary care in community-based settings is more efficient and can enhance quality.10
Hospital Processes/Waiting Times
In addition to the access problems that send patients to the ED for care, there are also throughput problems in EDs that contribute to crowding and inefficient care. An April 2009 GAO report found that a lack of inpatient beds is one of the main factors contributing to ED crowding.11 There is competition for inpatient beds between the ED and scheduled admissions like elective surgeries. Scheduled admissions are more profitable for a hospital and the lack of beds for emergency patients leads to boarding—the holding of admitted patients in the ED. The American College of Emergency Physicians (ACEP) considers boarding to be a high priority public health problem that compromises access to lifesaving emergency care. Proposed solutions include coordinating earlier discharge for patients, fast-tracking patients with non-urgent conditions, and the addition of observation units.12 Urgent Matters, a national program of the Robert Wood Johnson Foundation (RWJF) aimed at relieving ED crowding, provided technical assistance to 10 hospitals to test changes that might relieve crowding and improve ED operations. All participating hospitals reported a decrease in waiting times and the program disseminated best practices such as using a patient flow manager to ensure the timely transfer of ED patients to inpatient beds.13
EDs also face challenges from lack of current technology that might enable them to operate more efficiently. Research by RWJF Clinical Scholar Adam Landman, M.D., found that less than 2 percent of EDs have fully functional information systems in place and approximately 54 percent have no information systems at all.14 The presence of better information technology could aid in tracking patients and improve clinical decision-making. Lack of electronic clinical decision support systems such as physician reminders, safety alerts, and the automatic incorporation of clinical guidelines limits providers’ ability to prevent overuse and delays. A recent study in the Journal of the American Medical Association found that use of advanced radiology such as CT scans and MRIs increased significantly between 1998 and 2007, with no corresponding increase in life-threatening conditions.15
Geography and Safety Net Changes
Arecent HCFO-funded study addresses one facet of the problems facing EDs. In her study on changes in ED access between 2001 and 2005, Yu-Chu Shen, Ph.D., analyzed how driving times to the nearest ED had changed during the time period and also focused on vulnerable populations to see if access worsened for this group. While 95 percent of communities did not experience a decrease in access, Dr. Shen found that low-income communities and communities with high shares of Hispanic populations were disproportionately more likely to experience access deterioration.16
The ED is part of the health care safety net and the vulnerable populations that rely on ED services are also those that have the most difficulty accessing physician appointments. For example, although Medicaid reimbursement fees and enrollment increased between 1996 and 2005, the number of physicians who accept Medicaid patients declined during the same time period.17 Medicaid patients typically have limited or no copayments, which reduces the financial barrier to accessing ED services.18 However, a recent study in Health Affairs showed that requiring copayments from Medicaid patients for ED services did not decrease use for non-urgent conditions.19 These results suggest that the access crisis is particularly acute for low-income patients.
Alternative Access Points
In a recently-funded HCFO grant, Ateev Mehrotra, M.D., will examine a potential alternative care site—the retail health clinic. Retail clinics are often located inside of national drugstore chains and treat common acute conditions such as sinus and ear infections. Dr. Mehrotra’s project will determine if the presence of these clinics raises costs by encouraging utilization when patients might have previously stayed at home, or if they decrease costs by substituting for ED visits. Some health plans have encouraged their enrollees to use these clinics for simple acute care conditions, and this project seeks to shed light on the potential benefits and drawbacks of these policies.
Other access points include community health centers (CHCs) and freestanding EDs. While CHCs provide quality care to low-income patients in community-based settings, they often suffer the same resource constraints as safety net hospitals. These include low Medicaid reimbursement, demand that exceeds capacity, and long waits for appointments.20 Another option is freestanding EDs. Although these facilities have existed for almost 40 years, there is now renewed interest in light of the capacity problems in hospital EDs. These facilities may be owned or co-located by a larger hospital, and are able to perform more advanced procedures than retail clinics. Research indicates that these facilities can provide easier access and faster throughput, but there are concerns about the lack of on-call specialists and the scope of services that these facilities provide.21
Conclusion
Assuring adequate access to emergency services is a complex problem. It is a symptom of the larger challenges of access and capacity facing the entire health care system. As more Americans gain insurance coverage and seek access to medical care services, the strain on hospital EDs is likely to continue. The need to relieve ED crowding and to find alternative and more cost-affective methods of care will remain pressing. Details on the studies led by Dr. Shen, Dr. Mehrotra, and other HCFO grantees are available at http://www.hcfo.org.
Title: Effect of Decreased Emergency Department Access on Patient Outcomes
Grantee Institution: Naval Postgraduate School
Principal Investigator: Yu-Chu Shen, Ph.D.
Grant Period: April 1, 2008-November 30, 2010
The researchers will examine whether decreased emergency department (ED) access results in adverse patient outcomes or changes in other health indicators. There is a great deal of literature documenting decreased access to EDs. However, there is little empirical evidence linking access to EDs and health outcomes. The researchers will use acute myocardial infarction (AMI) patients to examine health outcomes, since AMI patients are relatively homogeneous and the time sensitivity of treatment should be reflected in differences in outcomes. They will examine two types of ED access between 1995 and 2005: permanent ED closure and temporary ED closure as measured by ambulance diversion time. Specifically, the researchers will focus on how changes in distance to the closed ED affect health outcomes of two types of AMI patients: 1) those who survived the ambulance ride and have an outpatient claim from the ED; and 2) those who survived the ED admission to have an inpatient claim. The objective of this project is to provide improved understanding of the impact of ambulance diversion in the health care system.
Title: The Impact of Retail Clinics on Overall Utilization of Care
Grantee Institution: RAND Corporation
Principal Investigator: Ateev Mehrotra, M.D.
Grant Period: November 1, 2010-April 30, 2012
The researchers propose to examine the impact of retail health clinics on health care utilization and costs. Specifically, they will assess whether the entry of retail health clinics into a community is associated with a change in the overall utilization of retail-clinic sensitive conditions—eight simple acute care conditions that make up the majority of retail health clinic visits—and will estimate the impact on costs of the entry of retail clinics. The researchers hypothesize that retail health clinic utilization could substitute for emergency department and physician office utilization, thus decreasing costs, or encourage utilization by those who would otherwise stay at home, thus increasing costs. The objective of this study is to shed light on the potential benefits and drawbacks of policies that encourage retail clinic use.