Hospital-Based Emergency Care At the Breaking Point (2007) / Chapter Skim
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2 The Evolving Role of Hospital-Based Emergency Care
2 The Evolving Role of Hospital-Based Emergency Care
Pages 37-80
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From page 37... ...
. Over four decades, the hospital ED has been transformed into a highly effective setting for urgent and lifesaving care, as well as a core provider of ambulatory care in many communities.
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FIGURE 2-1 Hospital EDs versus ED visits.
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. The most common cause of this bottleneck is the inability to admit critically ill patients because all of the hospital's intensive care unit (ICU)
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. Another study, using data from the National Emergency Department Overcrowding Study, found that academic medical center EDs were crowded on average 35 percent of the time.
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. A report using data from the 2003 National Hospital Ambulatory Medical Care Survey indicated that 501,000 ambulances were diverted in 2003 (Burt et al., 2006)
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. THE EMERGENCY DEPARTMENT AS A CORE COMPONENT OF COMMUNITY AMBULATORY CARE The "Safety Net of the Safety Net" Hospital EDs are the provider of last resort for millions of patients who are uninsured or lack adequate access to care from community providers.
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Without the ED to fall back on, other community safety net services would be equally overwhelmed. Thus, the emergency care system truly has become the "safety net of the safety net." Use of the ED for Nonurgent Care Just over half of ED visits in 2003 were categorized as emergent or urgent, translating into a need for care within 15 minutes to 1 hour of arrival at the ED, while about 33 percent of visits were categorized as semiurgent or nonurgent, requiring attention within 1 hour or 24 hours, respectively (McCaig and Burt, 2004)
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Despite its importance in providing ambulatory care and the legal requirement to accept all patients regardless of insurance coverage or ability to pay, hospital emergency care receives little direct federal support.
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For example, many provide primary care services but lack the resources to provide specialty care and diagnostic services. Results of a recent study suggest that expanding primary care capacity may actually increase demand for ED care (Cunningham and May, 2003)
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The second most common option was to tell the caller to seek care in an ED. A national study of ambulatory use of hospital EDs revealed that 19 percent of "walk-in" patients had been instructed to seek care in the ED by a health care provider (Young et al.,
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Chronic disease management, medication management, counseling, and case management resources, on the other hand, are aspects of care that primary and specialty care ambulatory practices should be able to provide as an alternative to the ED. Patient preference Patients are increasingly using the ED for the convenience of obtaining timely resolution of health care problems (Young et al., 1996; Guttman et al., 2003)
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Second, nonurgent ED utilization may be less cost-effective than care provided in other settings. EDs and trauma centers are expected to provide a full array of services around the clock, and the fixed costs associated with maintaining this readiness can be substantial.
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Scheduled Versus Unscheduled Visits A useful way to conceptualize the utilization of ED services is to consider them within the broad context of all health care services within a community. Services can be categorized according to whether they are scheduled or unscheduled.
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b. Not Chronic Chronic Not Chronic Chronic S Preventive Chronic Disease Preventive Chronic S c c Disease Services Management Services h h Management e e d d u u l l ED Visits e e d d U Acute Acute n s Acute Episodic Acute Episodic Exacerbations of Exacerbations U ED Visits c Illness and Injury Illness and Injury n Chronic Disease of Chronic h e s Disease d c u l h e Life-Threatening Emergencies e d d u l e d Life-Threatening Emergencies FIGURE 2-4a Current distribution of all care visits.
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Figure 2-4a represents a hypothetical distribution of medical services between EDs and other providers that is typical of many communities today. Preventive services and chronic disease management are provided mainly outside the ED, while acute illnesses and exacerbations of chronic disease are often treated in the ED.
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REIMBURSEMENT FOR EMERGENCY AND TRAUMA CARE Substantial evidence demonstrates that reimbursement to safety net hospitals is inadequate to cover the costs of emergency and trauma care. Of the 114 million ED visits in 2003, 36 percent of patients had private insurance, 21 percent were enrolled in Medicaid or the State Children's Health Insurance Program (SCHIP)
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provides DSH payments to these 2-5 hospitals, as well as payments for treating undocumented aliens. A number of states also provide additional support 10 emergency and trauma care april to systems through general revenues or special taxes.
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. Current legislative proposals would fold DSH payments into block grants, further diluting their contribution to the funding of safety net emergency and trauma care.
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. 1According to this standard, health insurers must cover emergency services obtained by patients if a reasonable layperson would have interpreted the symptoms as requiring emergency care, regardless of whether the patient sought prior authorization from the insurer.
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A 2MEPS data given here are based on Tsai and colleagues (2003) and calculations by McCon nell and Lindrooth, as reported in their commissioned paper for this study, "The Financing of Hospital-Based Emergency Department Services and Emergency Medical Services" (available upon request)
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Public trauma centers had a median operating loss of $18.6 million, a 54 percent increase over the previous year. Private/nonprofit trauma centers had a median operating loss for trauma care of $5.5 million.
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Consequently, the committee believes that the emergency care system requires a special funding source, separate from the regular DSH formula, to compensate hospitals and physicians adequately for the burden of providing services to uninsured and underinsured populations. To ensure the continued viability of a critical public safety function, the committee recommends that Congress establish dedicated funding, separate from Disproportionate Share Hospital payments, to reimburse hospitals that provide significant amounts of uncompensated emergency and trauma care for the financial losses incurred by providing those services (2.1)
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Pennsylvania guaranteed support to its trauma care system by modifying its insurance statutes to ensure that accredited trauma centers would receive hospital and professional reimbursement at the charges level, rather than the more common and lower Medicare level, for all motor vehicle crash–related care and workmen's compensation patients. Other states rely on a wide range of funding mechanisms.
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0 TABLE 2-1 Revenue Sources to Fund Trauma Care, Organized by Topic Source AZ CO FL IL KS MD MI NE OH OK PA TX UT VA WA 911 System Surcharges X Controlled Substances Act Violations X Court Fees, Fines, and Penalties X X X X Intoxication Offenses -- Not Limited to Motor Vehicles X Motor Vehicle Fees, Fines, and Penalties X X X X X X X X X X X X • Motor vehicle registration X X X X • Tax on motor vehicle license X • Driving under the influence (DUI) -related X X X • Fee for distinctive license tags X • Violations of child restraint laws X X • Seat belt violations X X • Open container violations X • Driver's license fee X • Fee for reinstating revoked license X X • Driving with revoked or suspended license X • Fine on specific traffic violation X X X • Non–motor vehicle intoxication X • Sale or lease of new vehicle X Sales Surtax X Tobacco Tax X Trauma Facility Penalty X Tribal Gaming X Weapons Violations X SOURCE: HRSA, 2004.
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were discharged home without plans for addressing the impairment. The authors suggested that the lack of documentation and referrals indicates a lack of recognition of mental illness by emergency physicians (Hustey and Meldon, 2002)
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Standardized psychiatric training is not required of residents in emergency medicine and pediatric emergency medicine. Fewer than one-quarter of emergency medicine residency programs provide formal psychiatric training for residents (Santucci et al., 2003)
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. In a recent national survey, 6 in 10 emergency physicians said the increase in psychiatric patients seeking care at EDs is negatively affecting access to emergency care for all patients by generating longer waiting times and limiting the availability of ED staff and ED beds for other patients (ACEP, 2004)
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. This situation has been demonstrated by a number of studies even though numerous federal and expert panels have recommended routine screening of injured patients in the ED for substance abuse and the provision of brief interventions for those that test positive (Gentilello, 2003)
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A recent IOM study, Quality through Collaboration: The Future of Rural Health, documented the difficulties faced by rural communities in providing high-quality medical services, particularly emergency care (IOM, 2004)
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Given the high cost of maintaining trauma centers and the difficulty of maintaining them even in busy urban areas (Taheri et al., 2004) , it is unrealistic to expect that each rural ED will have the full spectrum of trauma resources available.
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. The large numbers of uninsured in rural areas can have spillover effects on the community, reducing access to emergency services, trauma care, specialists, and hospital-based services (Kellermann and Snyder, 2004)
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. The proportion of physicians who are board certified in emergency medicine is also very low in rural areas -- 67 percent of rural emergency medicine physicians are neither emergency medicine residency trained nor board certified.
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The fact that the patient census in a rural ED may be very low likely contributes to the difficulty experienced by physicians and midlevel providers in maintaining a high level of proficiency in emergency medicine. Distance and Time Factors Long distances and times involved in the transportation of acutely ill and traumatized patients in rural regions likely affect health outcomes adversely.
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pointed out that with respect to out-of-hospital cardiac arrest, rates of survival to discharge were reported to be as high as 32 percent in urban studies, compared with less than 10 percent in most rural studies. SUMMARY OF RECOMMENDATIONS 2.1: Congress should establish dedicated funding, separate from Disproportionate Share Hospital payments, to reimburse hospitals that provide significant amounts of uncompensated emergency and trauma care for the financial losses incurred by providing those services.
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2004. Emergency Departments See Dramatic Increase in People with Mental Illness -- Emergency Physicians Cite State Health Care Budget Cuts at Root of Problem.
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2001. Acute stroke care in non-urban emergency departments.
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emergency departments. Academic Emergency Medicine 8(2)
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2003. Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities.
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2002. Trends in the use and capacity of California's emergency departments, 1990–1999.
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2002. Children presenting to emergency departments with mental health problems.
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Academic Emergency Medicine 8(5)
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2003. Assessing substance abuse treatment need: A statewide hospital emergency department study.
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1996. Ambulatory visits to hospital emergency departments.
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