The Health Care Safety Net: Intact or Unraveling?
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Transcript The Health Care Safety Net: Intact or Unraveling?
Emergency Department Utilization:
Facts and Myths
Lynne D. Richardson, M.D., F.A.C.E.P.
Vice Chair and Associate Professor
Department of Emergency Medicine
Mount Sinai School of Medicine
August 26, 2009
THE FACTS
Emergency
Department Utilization
– Who?
– Why?
Emergency
– What?
– Why?
Department Crowding
MYTH #1:
“Increasing penetration of
managed care will
decrease the use of
emergency departments.”
Annual U.S. ED Visits & EDs
1995 – 2006 (NHAMCS)
2006
The Emergency Department:
A Unique Care Provider
Immediate care available
24 hours/day; 7 days/week
Complex life-saving interventions – simple
first aid
access, regardless of ability to pay,
mandated by federal law (EMTALA)
only available access to care for many
vulnerable and disenfranchised individuals
The Emergency Department
The Ultimate “Safety Net” Provider
ED disproportionately used by:
patients without insurance
patients with Medicaid
patients without primary care physicians
members of racial and ethnic minorities
other “vulnerable populations”
MYTH #2
“Emergency departments are
used mainly by patients who
have nowhere else to go:
uninsured, illegal immigrants,
homeless, etc, etc.”
ED Visit Rates by Payment Source
(NHAMCS 2006)
ED Visits by Payment Source
(NHAMCS 2006)
50,000
45,000
40,000
47284
35,000
30,000
25,000
20,000
15,000
30351
23672
20777
10,000
5,000
0
Medicare
Medicaid
Private
Uninsured
U.S. Hospital Admissions by Route
(NHAMCS 1996, 2006)
U.S. ED Visit Rates by patient age,
race & ethnicity: 2005
(NHAMCS)
MYTH #3
“There is frequent misuse
or inappropriate use of the
ED for non-urgent
problems”
ED Patient Acuity
(NHAMCS 2006)
5%
< 1 minute
13%
11%
1-15 minutes
15-60 minutes
12%
1 - 2 hours
37%
>2 hours
22%
Unknown
EMPATH: Emergency Medicine
Patients’ Access to Healthcare
Principal Reasons for Coming to the ED
Medical Necessity
ED Preference
Convenience
Affordability
Limitations of Insurance
Ragin et al, Acad Emerg Med 2005
EMPATH Study: Conclusions
Use of the ED is driven by:
comprehensive scope of services
Immediate availability of services
quality of care provided
lack of affordable alternatives
Emergency Department CROWDING
Definitions & Measures
Causes of Crowding
Impact on patient
outcomes
Short term strategies
Long term solutions
ED Crowding: Asplin’s Model
ED Crowding: “Upstream” (INPUT) Issues
Inadequate primary care capacity
Insufficient “walk in” & off hours
availability of PCPs
Increasing number of uninsured
Declining Medicaid enrollment
Declining coverage for immigrants
Less funding for uncompensated care
ED Crowding: THROUGHPUT issues
Increasing acuity
Increasing volume
Staff shortages: particularly nurses
Operational inefficiencies:
– Registration
– Laboratory
– Radiology
– Consults
ED Crowding: OUTPUT Issues
Boarding of admitted patients
Decreasing hospital bed capacity
Institutional / organizational culture
Declining reimbursement
Shrinking hospital profit margins
Decreased primary care capacity
Insufficient access to specialty care
ED Boarding of Admitted Patients
Often cited as #1 cause of ED Crowding*
62.5% hospitals board admitted patients**
– 14.9% “board” on inpatient units
– 35.6% observation/clinical decision unit
– 35.2% electronic dashboard
– 21.1% full capacity protocol
19.5 % expanded ED within past 2 years
31.5% have ED expansion plans
*GAO Report; ACEP Task Force;
**NHAMCS 2007 E-Stat
Adverse Impact on Outcomes
Increased waiting times
Increases in leaving without treatment
or AMA
Increased risk of in-hospital mortality
Increased time to antibiotics for
pneumonia
Reduced promptness & quality of pain
management
“ Knowing is not enough, we must apply.
Willing is not enough, we must do.”
Goethe
RWJF Urgent Matters Program
National program to develop solutions
to ED Crowding
Elmhurst Hospital one of ten sites
Results released May/June 2004
summary available at
http://www.urgentmatters.org
Institute of Medicine Report on
Future of Emergency Care in
the United States
Key Findings & Recommendations
– released June 2006
Hospital-Based ED Care
Emergency Care for Children
Pre-hospital Emergency Care
IOM Future of Emergency Care
Recommendations
Improve hospital efficiency & patient flow
A coordinated, regionalized, accountable
EMS system
Increased reimbursement
Increased resources for research &
disaster preparedness
Focused attention to care of children
Cost of Care in the ED
Williams, R. NEJM, 1996.
– ED: High fixed costs; low marginal costs
– True costs of non-urgent care in the ED are relatively low
Tyrance, P. AJPH, 1996
– Only 12% of “ED spending” by uninsured
– ED expenditures only 1.9% of US health costs
– Decreasing ED use will not generate much overall
US health cost savings