Some findings in the retrospective analysis of emergency department (ED) utilization and hospital admission trends in the last decade reported by the RAND Corporation in May, 2013 were not surprising. Some patients refer themselves to EDs because they have no other way to access first-contact care. Others use the ED because their primary source of care is not available after hours, weekends, or holidays. But other findings by the RAND research group were more surprising. Four out of five patients who succeed in contacting their doctor about an urgent illness or injury are referred to the ED. Primary care providers (PCPs) today are increasingly likely to refer patients to the ED to determine whether they need to be hospitalized.
In fact, scheduled admissions for elective procedures and treatment remained flat across all major payer classes in the post-millennial decade studied by RAND. The only growth in hospitalizations occurred from the ED, which is now responsible for more than half of all hospitalizations. So what is the role of the ED in this context?
This pathway of admission via the ED, as one might expect in the era before the Affordable Care Act, has been crucial for those without health insurance coverage. Three out of four hospital admissions for the uninsured are the direct result of an ED visit. And uninsured patients are usually admitted at a more advanced stage of their illness than are insured patients, therefore requiring longer hospital stays and incurring higher rates of co-morbidity and cost. Improving access to ambulatory care to prevent this remains one of the key rationales for the extension of coverage to tens of millions under ObamaCare. But RAND concludes that emergency physicians have become the national experts on the most important decision for ED patients in ALL health plans – whether they can be safely referred without immediate hospitalization after screening and stabilization.
The RAND finding with the greatest implications for policy makers is the one which flies in the face of conventional wisdom about ‘expensive’ ED care. The largest component of growth in admissions from the ED was the Medicare population. And the principle driver was expansion in the number of seniors and permanently disabled Americans who are eligible for Medicare. But the paradox is that the admissions to the hospital are not growing as rapidly as scientists would expect from the growth of the Medicare population, the widely heralded and feared “Boomer Effect.” RAND found evidence that for a number of diagnostic categories such as congestive heart failure and asthma, admissions from the ED were actually lower than predicted—not because of improved primary care, but as a result of interventions by acute care providers and better transitions of care.
RAND’s findings won’t astonish most emergency physicians. In many communities, their approach to ED patients who may need hospitalization has been evolving since the study period began in 2003. As some hospitals have closed and others have consolidated, inpatient capacity has decreased – especially for unscheduled patients being admitted from the ED. The RAND study, as well as other peer-reviewed articles published recently in the New England Journal of Medicine and the Annals of Emergency Medicine, suggests that the future role of the ED will be to serve as the hub linking community-based health care providers with the higher technologies only available in hospital settings. In the new paradigm, the role of emergency physicians, hospitalists, and providers of post-acute care will be different. Their job will be to identify patients whose needs can be safely and more cost-effectively met by methods that pre-empt the need for lengthy and far more costly inpatient stays, such as rapid diagnostic evaluation, early intervention, and innovative transitions of care.
If Smulowitz and the other authors of the recent study in the Annals are correct, there is simply not enough system savings to be garnered from diverting low-acuity patients away from the ED. The RAND study extends the alternative suggested in the Annals, that EDs can add more value by helping control the largest cost center of all – nearly 31% of health expenditures for inpatient care. Other voices in this new chorus include Schuur and Venkatesh, whose study of hospitalization trends in the New England Journal of Medicine shows that EDs are already bending the cost curve on admission rates for chest pain with observation protocols to rule out heart attacks in a matter of hours, rather than inpatient days.
As RAND concluded, while ED visits have an average cost of $900, the cost of a single hospital admission is “ten times higher." It is likely that the future solvency of Medicare will depend on ED-based teams who safely and cost-effectively reduce rates of admission and readmission to hospitals If so, the continuum of acute care providers will be just as important to a sustainable US healthcare system as improved access to primary care.
[Image credit: "Emergency_room" by Thierry Geoffroy licensed under CC BY-SA 3.0]