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