The Affordable Care Act and Emergency Care

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.The Affordable Care Act (ACA) focuses on improving access and quality by expanding insurance coverage, using payment reform strategies, and increasing quality reporting.1 In the ACA, hospital-based emergency departments (EDs) are referenced as places to be avoided and reduced; no new payment models focus on ED care, and there are no plans to broadly address ED-specific quality through new measurement programs.Promoting value in ED care needs to be a greater focus for policymakers as the ACA is implemented. Emergency departments play a central role in health care delivery as the staging area for the ill and injured, and as an always-available resource for unscheduled care. Emergency department physicians constitute less than 5% of the US physician workforce, yet manage 28% of acute care encounters.2 Historically, the need for EDs arose from increases in vehicular trauma that accompanied the expansion of the Interstate Highway System in the 1960s.3 However, EDs also quickly became providers of low acuity unscheduled care as well.4 The Emergency Medical Treatment and Active Labor Act legislation passed in 1986 institutionalized EDs as provider of last resort for all, regardless of their ability to pay. Emergency departments have replaced the community physician’s office as the primary source for hospital admissions and provide a safety net for the uninsured, underinsured, and medically disenfranchised.5,6Several elements of the ACA—the insurance expansion, patient-centered medical homes, accountable care organizations, and bundled payments—will directly affect both demand for ED care and expectations for its role in providing coordinated care. We explore these effects and suggest some practical ways that EDs can be better integrated into these efforts.     

Data-driven process and operational improvement in the emergency department: the ED Dashboard and Reporting Application

Emergency departments (EDs) in the United States are expected to provide consistent, high-quality care to patients. Unfortunately, EDs are encumbered by problems associated with the demand for services and the limitations of current resources, such as overcrowding, long wait times, and operational inefficiencies. While increasing the effectiveness and efficiency of emergency care would improve both access and quality of patient care, coordinated improvement efforts have been hindered by a lack of timely access to data. The ED Dashboard and Reporting Application was developed to support data-driven process improvement projects. It incorporated standard definitions of metrics, a data repository, and near real-time analysis capabilities. This helped acute care hospitals in a large healthcare system evaluate and target individual improvement projects in accordance with corporate goals. Subsequently, there was a decrease in "arrival to greet" time--the time from patient arrival to physician contact--from an average of 51 minutes in 2007 to the goal level of less than 35 minutes by 2010. The ED Dashboard and Reporting Application has also contributed to data-driven improvements in length of stay and other measures of ED efficiency and care quality. Between January 2007 and December 2010, overall length of stay decreased 10.5 percent while annual visit volume increased 13.6 percent. Thus, investing in the development and implementation of a system for ED data capture, storage, and analysis has supported operational management decisions, gains in ED efficiency, and ultimately improvements in patient care.     

Cost Reduction Strategies for Emergency Services: Insurance Role, Practice Changes and Patients Accountability

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999–2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to “stabilize” a patient suffering from an “emergency medical condition” before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users’ characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.     

Re‐structuring the negotiated order of the hospital

Researchers continue to lament the lack of organisational focus in the sociology of health and illness. Although studies have increasingly focused on boundaries between organizations, little such research has focused on the formal boundaries within the hospital itself. Given its dramatic compartmentalisation, and continuing prevalence in health systems, the lack of organisational perspective in hospital research limits insights into the effects (as well as the construction) of the order of health work and care. With a greater emphasis on ‘ordering’ in the concept of negotiated order, the aim of this study is to examine the manifestation and consequences of the formal boundaries of hospital departments. Fieldwork featured 12 months of ethnography, including formal and informal observations, 80 audio‐recorded, semi‐structured interviews, and 56 field interviews, in the Emergency Departments (EDs) of two tertiary referral hospitals. Compared with in‐patient hospital departments, the ED has limited legitimacy claims of organ‐specific knowledge to transfer patients out of the ED. The manifestation of specialised knowledge hierarchies in organisational structures disadvantages patients who are older and who have chronic conditions, underpinning the argument that effects as well as the negotiation of stable organisational orders deserve increased attention in the sociology of health and illness.     

Impact of nurse staffing level on emergency department market share

BACKGROUND: Emergency departments (EDs) function at the interface of complex systems of the hospital and play a critical role in safety net systems. Adequate level of nurse staffing is crucial in meeting patients' needs and assuring their safety in EDs. PURPOSES: This study examined the impact of nurse staffing on ED market shares. METHODOLOGY/APPROACH: Data were collected from 122 hospitals operating nationally designated emergency medical centers. Multiple regression analyses were conducted to explain ED market share with the nurse staffing level. FINDINGS: After controlling for hospital and regional characteristics, nurse staffing level significantly influenced market shares. Specifically, increasing one level from the baseline nurse staffing resulted in 29% higher ED market share. PRACTICE IMPLICATIONS: Higher nurse staffing level is sensitively linked to the higher market share in emergency care services. These findings provide an initiative for hospital managers and nurse administrators to recruit and retain more nurses for pursuing higher nurse staffing. Furthermore, continuous effort should be made to develop a high standard of establishing and maintaining an adequate level of nurse staffing.     

Does better access to primary care reduce utilization of hospital accident and emergency departments? A time-series analysis

BACKGROUND: Availability of primary care emergency facilities has been improved to help curb heavy growth in the use of Accident and Emergency Departments (A&EDs). The aim of this paper is to analyse the relationship between time series for visits to hospital A&EDs and primary care centres. METHODS: Using a co-integration time series we analyse the visits to the emergency services of the county hospital and seven healthcare primary centres in the healthcare district of Mieres, Asturias, Espa?a, during the period 1992-1999. The main outcome measured is the relationship between the time series for emergency visits to the primary care centres and the hospital A&ED, for groups aged 0-14 years, over 14 years and the total. RESULTS: A total of 506,158 visits to the emergency services of the primary care centres (62.4%) and hospital A&ED (37.6%) have been studied. Emergency visits rose by 40.9% during the period studied (50.3% in primary care centres and 26.5% in the hospital). The gross rise in visits was higher for adults (51.2%) than for 0-14 year olds (6.6%). The co-integration time-series analysis showed that in both age groups and in the total, there was a significant and positive relationship between the primary care and hospital series, indicating that the use of both services had grown simultaneously. The use of the hospital services did not decrease as a result of the increase in primary care services. CONCLUSIONS: The rise in use of primary care emergency services did not reduce use of the hospital A&ED.     

Availability of pediatric services and equipment in emergency departments: United States, 2002-03

OBJECTIVES: This report presents estimates on the availability of pediatric services, expertise, and supplies for treating pediatric emergencies in U.S. hospitals. METHODS: The Emergency Pediatric Services and Equipment Supplement (EPSES) was a self-administered questionnaire added to the 2002-03 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS samples non-Federal, short-stay and general hospitals in the United States. The EPSES content was based on the 2001 guidelines for pediatric services, medical expertise, small-sized supplies, and equipment for emergency departments (EDs) developed by the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP). Combined response rate for both years was 86 percent. Estimates were weighted to produce average annual estimates of pediatric services, expertise, and equipment availability in EDs. RESULTS: One-half of hospitals (52.9 percent) admitted pediatric patients, but did not have a specialized inpatient pediatric ward. One-third (38.3 percent) admitted pediatric patients and had a separate pediatric ward; the remainder did not admit pediatric patients. Among those that did not admit pediatric cases, 30.4 percent were in counties that had a children's hospital. One-quarter of EDs had access 24 hours and 7 days a week to a board-certified pediatric emergency medicine attending physician. Only 5.5 percent had all recommended pediatric supplies, but one-half had greater than 85 percent of recommended supplies. Most hospitals without pediatric trauma service (90.7 percent) or pediatric intensive care units (97.5 percent) transferred critical pediatric patients to hospitals with these services. EDs in hospitals with specialized inpatient facilities for children were more likely to meet the AAP and ACEP guidelines for pediatric ED services, expertise, and supplies.     

Overcrowding and fiscal pressures in emergency medicine

Emergency departments in America are disappearing at an alarming rate. Those that remain face a daily ordeal of overcrowding and budgetary shortfalls. The reasons for this phenomenon include changes in reimbursement rates by managed care organizations, the nationwide reduction of hospital beds, the nursing shortage, a more acute patient mix, and a general deterioration of the healthcare safety net. Another reason--more vital today than ever before--is the uncompensated integration of EDs into governmental disaster planning and response. Despite their importance to society, the emergency department is the first to be cut. Emergency departments are much more than the nation's last line of defense for the medically indigent; they are the frontline caregivers to all of us, providing care during our most vulnerable times: emergencies and disasters.     

National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary

OBJECTIVES: This report describes ambulatory care visits to hospital emergency departments (EDs) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1992 through 2001 are also presented. The report highlights new items on the continuity of care provided at ED visits, initial vital sign measurements, whether the patient's residence was a nursing home or institution, and duration of the ED visit. METHODS: The data presented in this report were collected from the 2001 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2001, an estimated 107.5 million visits were made to hospital EDs, about 38.4 visits per 100 persons. From 1992 through 2001, an increasing trend in the ED utilization rate was observed. Between 2 and 3 percent of ED visits were made by patients living in a nursing home or other institution. At approximately 3 percent of visits, the patient had been seen in the ED within the last 72 hours. In 2001, abdominal pain, chest pain, fever, and headache were the leading patient complaints accounting for nearly one-fifth of all visits. Acute upper respiratory infection was the leading illness-related diagnosis at ED visits. There were an estimated 39.4 million injury-related visits during 2001, or 14.1 visits per 100 persons. Diagnostic/screening services and procedures were provided at 85.4 percent and 40.9 percent of visits, respectively. Medications were provided at 74.2 percent of visits, and pain relief drugs accounted for 34.2 percent of the medications mentioned. In 2001, approximately 12 percent of ED visits resulted in hospital admission. On average, patients spent 3.0 hours in the ED.     

Infectious diseases treated in emergency departments: United States, 2001

Emergency departments (EDs) are an important source of medical care in the United States. Information is limited concerning epidemiologic patterns of ED visits for infectious diseases. Data for 2001 from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed for infectious disease visits. The NHAMCS is a national probability sample survey of visits to hospital EDs and outpatient departments of non-federal, short-stay, and general hospitals in the United States. Data are collected annually and are weighted to generate national estimates. In 2001, an estimated 19.8 million visits were made to hospital EDs for infectious diseases (rate=71 visits/1,000 persons). Children under 15 years old made 36% of these visits and had the highest rate of visits (rate=119 visits/1,000 persons). The rate of visits for females was 37% higher than for males (82 versus 60/1,000 persons). Although the white population had the highest volume of visits, the rate of visits for blacks was more than twice that of whites (130 versus 64 visits/1,000 persons). Laboratory tests were ordered in 84% of visits. An estimated 18% of visits to the EDs concern infectious diseases. The issue of health care access and ED use is complex and the reasons for the higher rate of visits for blacks than for whites are not fully understood.