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H E A L T H T R A C K I N G
F R O M T H E F I E L D
W E B E X C L U S I V E
24 March 2004
The Emergency Department:
Rethinking The Safety Net For The Safety Net
The ED is a key element of today’s
health care system,
and it needs to be given adequate support to expand beyond its traditional role.
By Bruce Siegel
ABSTRACT:
America’s emergency departments (EDs) are in crisis. The dwindling numbers
of EDs are increasingly overcrowded as they cope with rising demand. In a Health
Affairs Web Exclusive, Glenn Melnick and his colleagues find that despite
these trends, overall ED capacity is actually increasing in California. While
this may appear to make financial sense for some hospitals, it is a costly response
that does little to fix the complex problems that drive ED overcrowding. Given
a convergence of factors, it may now be time to radically alter and broaden
our historical expectations of the role of the ED.
The crisis of overcrowded emergency departments (EDs) has been documented in
the popular media as well as several systematic surveys.1
Consumers and administrators alike report long waits to see a health professional,
patients forced to occupy a bed in the ED hallway for hours or even days before
being admitted, and large numbers of patients simply giving up and leaving the
ED before receiving medical attention. A host of factors are blamed for this,
including a rising demand for ED services, shortages of hospital nurses and
on-call specialist physicians in the ED, reduced inpatient capacity, and an
increased willingness of physicians to direct their patients to the ED for faster
diagnostics.
The study by Glenn Melnick and colleagues seeks to determine whether, as widely
reported, economic pressures are forcing California hospitals to exit the ED
market.2 This would be especially alarming given
the recent increase in ED visits they document there. The authors analyzed the
California ED market and instead find a much more complex picture in which the
number of hospitals with EDs may be declining, but overall capacity is actually
increasing.
These findings are especially intriguing given the main drivers of ED overcrowding.
Several studies and our own work point to high hospital occupancy with shrunken
inpatient capacity (especially in critical care) and impaired patient flow as
the major determinants of backups in the ED.3 Hospitals
are simply unable to promptly move their sickest (and most resource-intensive)
patients from the ED to an inpatient bed. Instead, these patients are left as
“boarders” in the ED, consuming already scarce staff time and physical
space. The response by California hospitals to essentially build more ED capacity
thus may not represent the most rational allocation of resources. They might
be better served by functionally increasing inpatient capacity through speeding
the complex processes by which admitted patients move out of the ED to inpatient
units, or simply adding bed capacity where needed. The strategy of a bigger
ED may be driven by a desire to be responsive to staff, physicians, and the
community, who all want the hospital to “do something” visible to
“solve” the problem of the crowded ED. But it may simply result in
a larger reservoir behind the bottleneck of moving patients out of the ED to
where they need to be.
The economics of ED operations may also not be straightforward. While Melnick
and colleagues may be correct in asserting that EDs are essentially profitable
for the “average hospital,” we also have to realize that hospitals
vary widely in their payer mix. Thus, an ED may indeed be profitable for a hospital
serving a well-insured clientele by facilitating paid admissions. But it may
be a severe drain for an institution in which half of the patients are uninsured.
The authors omitted trauma centers from their analysis; they may well have omitted
those institutions most likely to have the poorest revenue base and highest
costs. Subsidies like the disproportionate-share hospital (DSH) program may
partially compensate for this, but they generally do not come close to reimbursing
the full cost of uncompensated care. If the ED were a risk-free, unalloyed financial
boon, we probably would not be observing the current scenario in which investor-owned
specialty hospitals without EDs are proliferating.4
Much of the increased demand cited by Melnick and colleagues may be a result
of the Emergency Medicine Treatment and Active Labor Act (EMTALA) of 1986, which
requires hospital EDs to screen all patients and stabilize them if necessary,
regardless of their ability to pay. This is a unique mandate; the federal government
does not guarantee such expansive access to any other part of the health care
system. This has arguably made America’s EDs the ultimate provider of last
resort, without any funding specifically to meet this mission. Rising demand
for ED services should thus not come as a surprise, and hospitals’ efforts
to meet that demand (however imperfect) are to be expected. The capacity increases
noted by Melnick and colleagues would then simply reflect this role of the ED
as essentially the health care “safety net” in every community.
If this is the case, we will be forced to fundamentally rethink our expectations
for the ED. Historically, we have viewed it as a place of episodic care, where
serious illness and injury were quickly addressed and, it is hoped, cured, with
the patient admitted if necessary. Continuity of care was not considered an
issue. It was assumed that after their ED visit, patients would resume the “normal”
habit of seeing their doctor. But law and now practice seem to have changed
this scenario. Insured as well as uninsured patients increasingly use the ED.5
Often the majority of patient encounters in the ED could have been treated in
other settings, such as a clinic or doctor’s office.6
There are many theories as to why this is happening, including physicians directing
patients to the ED, consumers’ preferences and convenience, and fewer restrictions
by managed care organizations on ED use. However, regardless of the determinants,
the trends are toward more Americans’ being dependent on the hospital ED
for primary care. Given this, we may now have to redesign the ED so that it
has the staff and systems in place to ensure some level of continuity of care
and serve as the primary provider of care for the many who now seem to be dependent
upon it. This would entail increasing EDs’ ability to provide patient education
and case management, clinical information systems to better handle repeat users,
and a greater focus on “urgent care centers” and “fast tracks”
that some hospitals already operate adjacent to their ED. This acceptance of
the expanded role of the ED will not be popular in many quarters. But it may
be the most realistic response to what the market is telling us.
The views expressed here are the author’s and do not necessarily reflect
those of the Robert Wood Johnson Foundation or the George Washington University.
NOTES
1.U.S. General Accounting Office, Hospital Emergency Departments:
Crowded Conditions Vary among Hospitals and Communities, Pub. no. GAO-03-460
(Washington: GAO, 14 March 2003); and American Hospital Association, Emergency
Department Overload: A Growing Crisis, April 2002, www.hospitalconnect.com/aha/press_room-info/content/EdoCrisisSlides.pdf
(3 February 2004).
2.G.A. Melnick et al., “Emergency Department Capacity and
Access in California, 1990–2001: An Economic Analysis,” Health
Affairs, 24 March 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.136
(24 March 2004).
3. A.J. Forster et al., “The Effect of Hospital Occupancy
on Emergency Department Length of Stay and Patient Disposition,” Academic
Emergency Medicine 10, no. 2 (2003): 127–133; and GAO, Hospital
Emergency Departments.
4. “The Shifting Burden of Emergency Care,” New
York Times, 3 February 2004.
5. P.J. Cunningham and J.H. May, “Insured Americans Drive
Surge in Emergency Department Visits,” Issue Brief no. 70 (Washington:
Center for Studying Health System Change, October 2003).
6. J. Billings, N. Parikh, and T. Mijanovich, “Emergency
Room Use: The New York Story,” Issue Brief (New York: Commonwealth Fund,
November 2000); and unpublished data on ED use at ten hospitals, Urgent Matters
Program, George Washington University School of Public Health and Health Services,
January 2004.
Bruce Siegel (siegelmd{at}gwu.edu)
is a research professor in the Department of Health Policy, George Washington
University School of Public Health and Health Services, in Washington, D.C.
He directs Urgent Matters, a national program of the Robert Wood Johnson Foundation
focused on the health care safety net and emergency departments.
Read the original
article by Glenn Melnick et al., and related papers by W.
Wesley Fields, Arthur
Kellermann, C.
Duane Dauner, and a response
by Melnick et al.
DOI: 10.1377/hlthaff.W4.146
©2004 Project HOPE–The People-to-People Health Foundation, Inc.
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