As healthcare leaders look toward solutions, many have focused on the problem of "unnecessary" ED visits. The Centers for Medicare and Medicaid Services (CMS) has announced its commitment to combating the problem. Meanwhile, states like Utah, Florida and Washington have moved to enact financial penalties for Medicaid patients who utilize the ED for non-emergent care.
While pervasive, the idea of restricting ED access based on "appropriateness" begs several questions that typically go unanswered. In today's post, we'll take a closer look at the trend toward rising ED volumes and discuss humane approaches to meeting this growing demand.
Behind the Numbers
The available evidence suggests that expanded health insurance coverage leads to increased ED utilization, at least in the short term.
In 2008, Oregon expanded its Medicaid program on a lottery basis. The result was the creation of two randomized groups — one uninsured, one newly insured. During the next 18 months, ED utilization rose 40 percent among the insured group. Outpatient visits (in which the patient was not admitted to the hospital) accounted for the bulk of this growth.
Vituity is currently tracking the impact of expanded coverage under the ACA on ED utilization. Our data encompasses over 5 million patient encounters annually at 140 hospitals nationwide.
As in Oregon, we've noted a significant and sustained uptick in ED visits after the 2014 and 2015 open enrollment periods.
Medicaid managed care patients account for much of this new volume (represented by the upper orange line).
What's interesting (and a little surprising to us): our overall admission rate has remained steady over time.
One way to interpret this finding is to assume that the admitted patients had high-acuity medical conditions — in other words, true emergencies. This suggests that patients who are urgently in need of care are more likely to seek it out when they have health insurance in place.
For many of us, this scenario may seem implausible. How could anyone experiencing symptoms of a heart attack or stroke hesitate to seek help? And yet there's a robust body of evidence stretching back to the 1980s suggesting that Medicaid patients in particular are painfully cost-sensitive. For example, participants in the RAND Health Insurance Experiment were equally likely to discontinue medically necessary and unnecessary medication when faced with a copay. And a study by Soumerai found that even a $1 copay discouraged Medicaid beneficiaries from filling medically necessary prescriptions.
If we accept that the admitted patients were "appropriate" ED utilizers, it follows that restrictions on ED access could do real harm. "Solutions" like higher co-pays and pre-screening would likely discourage visits by emergent patients as well as those with minor medical issues.
Of course, the above interpretation turns on the assumption that emergency physicians admit only patients who meet the admissions criteria. In real life, physicians may be imperfect filters of "appropriate" admissions. It may be years before we have enough longitudinal data to draw any generalizations about the acuity of admitted patients. Until then, the possibility remains that many of our ED patients could have been safely treated in the primary care setting.
The Limits of Primary Care
Paul Auerbach, a professor at the Stanford University School of Medicine, recently took a patient-centered view of the "unnecessary" ED visit in his op-ed, "Why ER Visits for Non-Emergencies Aren't Going Away."
Auerbach argues that it's unreasonable to blame patients for emergency department crowding when they lack reasonable access to primary and after-hours care. Nor should patients be expected to determine what constitutes an "appropriate" ED visit. We need to improve the system, he argues, because we "can't teach economics lessons to patients who don't feel well."
So how do we improve the system? Here's Auerbach's conclusion:
We agree wholeheartedly that patients would benefit from improved access to primary care. But we disagree that it represents a solution to ED crowding for several reasons:
"The most urgent needs are to build primary-care and specialist capacity that will effectively and appropriately assist patients who otherwise must rely on the emergency department, develop telephone and video-assisted care, promote wellness, harness the power of digital health, and finally, educate and convince patients that the system will serve them. Until these problems are addressed, the emergency room will continue to be the main event, not a safety net." [Emphasis ours.]
- First, as noted above, there is some evidence that more truly emergent patients are utilizing the ED. Primary care access won't discourage these visits.
- Second, a recent study by RAND Corporation found that a significant number of patients presenting to the ED are referred by a primary care provider. Reasons include complex diagnostic workups, office overflow, after-hours care and facilitation of hospital admissions.
- But most significantly, the primary care system doesn't always have the resources to quickly diagnose and treat complex cases. By contrast, the ED provides immediate access to intensive diagnosis, therapy and (if needed) inpatient care.
In conclusion, the ED meets several important needs for patients that the primary care system can't.
An Alternative Approach
So what else can be done to meet the rapidly rising demand for emergency care? Auerbach touches on another possible solution:
We agree improving the efficiency and continuity of emergency care will go a long way toward both relieving ED crowding and easing the pain of the primary care physician shortage. This is the approach that Vituity has followed in helping its client hospitals meet the challenges of healthcare reform.
"Most of the time, the emergency department is a good entry point for health care, as long as the patient is then connected with other support. Emergency physicians know how to sort patients and offer treatment in a cost effective manner, with the decency and compassion patients deserve." [Emphasis ours.]
A 2008 ACEP report found that the most effective ways hospitals can decrease ED crowding is to reduce the boarding of admitted patients. This requires a high degree of integration between the ED and players across the hospital.
Vituity physicians facilitate this integration by aligning with hospital leadership to design and implement change initiatives. Some of our success stories include:
- The ED team at Pomona Valley Hospital Medical Center worked with departments across the hospital to implement a Capacity Alert System. Now when ED crowding reaches critical levels, personnel from hospitalists to facilities staff respond to help restore capacity.
- Emergency and hospitalist physicians at Sutter Roseville Medical Center worked together to clarify roles and expectations and implement a "Fast Pass" order set for routine pre-admission care.
- The ED team at Doctors Medical Center Modesto pioneered a Team Rapid Medical Evaluation process that allows them to safely treat low- and medium-acuity patients (up to ESI Level 3) in the ED's front end.
The Future Is Now
Our healthcare system is undergoing a rapid transformation, and it's anyone's guess what ultimate form it will take. However, we strongly believe that our system is moving toward increased access, making basic care available to all. Because the ED is probably the most efficient way to intensive care on a short turnaround time, we believe it should play a key role in that future.
So rather than discouraging patients from using the ED, let's look at ways to make ED care more efficient and integrated. By adding value to emergency care, we will help to ensure that each patient gets the care they need, regardless of acuity of diagnosis.
[Image credit: "Manchester Airport waiting room II" by liz west licensed under CC BY 2.0]