Unexpected drop-offs in demand cause worry
Experts: Decreases could affect resources
In the last few months of 2013 and the beginning of this year, some ED administrators around the country observed a curious variation in their data. Patient volumes were down compared to the same period in previous years, during a period of record cold in some areas and seasonal flu outbreaks. There are many theories about what could be driving down demand for emergency services, and they all have a degree of validity, according to Charles Shufflebarger, MD, medical director of the Emergency Medicine and Trauma Center at Indiana University Health Methodist Hospital in Indianapolis. But he suggests that none of the theories he has come across thus far fully explain the decreased ED volumes being reported.
"For much of the country, weather has been particularly harsh," says Shufflebarger, noting that some of the biggest decreases in ED volumes have been reported in the Midwest and Northeast, where weather has probably played a big role in depressing demand. In Indiana, for example, January ED volumes were down by 10% to 15% in most facilities, compared to a year ago, he says.
Also noteworthy is the unusual nature of this year’s viral season, including both influenza and respiratory syncytial virus (RSV). "Patients have been relatively ill, but not in large numbers," says Shufflebarger.
Other factors that may be playing a role include the growing number of high-deductible health plans, the increasing availability of alternative options such as urgent care centers, and the ongoing, systematic efforts to get people to increase their use of these other venues, notes Shufflebarger.
Whatever is driving the reduced demand, however, it’s a definite concern for ED administrators. "It is harder to plan for the needs of our patients when we are unsure about utilization patterns," says Shufflebarger. "If this trend is permanent, then we will all face adjustments in resources based on the decreased need."
Lower ED volumes, higher admissions
It was October of 2013 when Laura Pimentel, MD, MMM, CPE, chief medical officer for the Maryland Emergency Medicine Network and assistant professor of surgery in the Division of Emergency Medicine at the University of Maryland School of Medicine in Baltimore, began observing decreases in volume, ranging from 3% to 16%, in nine out of 14 ED facilities. However, she is not sure that these changes represent a pattern that will be sustained. "October through December is historically the lightest quarter of the year, but it was lighter than normal this year," she says.
Patients may be utilizing urgent care centers to a greater extent than they have in the past, but Pimentel is concerned that the economy may be less robust than what people have generally come to believe. "There might be an actual drop in all health services for financial reasons," she says. "That could be playing into this."
Indeed, there is considerable evidence that many hospitals have not fully recovered from declines in demand that first became apparent during the steep economic downturn in 2008. Franklin, TN-based Community Health Systems, Dallas, TX-based HCA, and Boston, MA-based Partners HealthCare have all reported declining admissions, although most experts believe the declines are at least partly the result of regulatory changes and the fact that an increasing number of procedures are now being performed on an outpatient basis.
Nonetheless, citing the experience that Massachusetts providers faced with state-level health care reform, many health economists predicted that the Affordable Care Act would drive up demand for emergency services among newly insured Medicaid recipients, and this clearly hasn’t happened in some of the states that have opted for Medicaid expansion — at least not yet. "We are anticipating that there will be pretty substantial increases in the number of Medicaid patients but I think that is still in the process of ramping up," says Pimentel. "It has been surprising in that most people were anticipating that health care reform would bring an increase in patient volume rather than a decrease."
Another curious observation in some of the reporting on this issue is that in areas in which ED volume is down, admissions from the ED have tended to increase. Pimentel sees some of this impact in her own numbers. "I think it suggests that patients who are going elsewhere are lower-acuity patients, so the urgent care volume — or the more discretionary users of emergency services — are the ones we aren’t seeing," she explains. "The true emergencies — the patients who are sick enough to require admission — are still coming to the ED, so just by diluting out the lower-acuity patients, we are seeing an increasing percentage of admitted patients."
While this is a change in utilization that payers and many health care organizations have been pushing for, Pimentel is worried that some patients may be going without care at all. "Most patients [who present to the ED] are sick enough to warrant being seen and treated, so I hope they are getting care in some setting, and that they are certainly getting the equivalent quality of care that they would be receiving in the ED," she says.
Re-evaluate scope of practice
Making sense of the numbers is difficult at this point, because while many EDs are seeing decreased volumes, others are seeing an influx of newly insured patients, and some hospitals in New York and California, for instance, are reporting that their ED volumes are continuing to increase in line with what they have seen in past years.
William Durkin, MD, MBA, FAAEM, president of the American Academy of Emergency Medicine (AAEM), addressed the issue at AAEM’s Annual Scientific Assembly in New York, NY, in February, noting that some members say volumes are up appreciably since the Affordable Care Act went into effect, while others say they are not as busy as they expected. Durkin anticipates that most EDs will eventually see increases in volume because of the dearth of primary care providers, but not everyone shares this view.
It’s clearly not a big issue if demand for emergency services bounces back to normal relatively quickly. "I think it will take three to six months to see if this is a trend or if it is background variation," says Shufflebarger. "The weather will normalize, but the structural changes in insurance and health care finance may drive trends. I personally believe that ED use will decrease, but I don’t know how much yet."
If the decreased volumes persist, ED directors and other emergency groups may have to adjust their staffing patterns and accommodate the lower volumes, says Pimentel. "It could be significant for the job market in emergency medicine if we just find ourselves overstaffed for what we are seeing," she says. "Then shifts would have to be cut and potentially providers could end up losing jobs."
However, emergency providers could push the field in a different direction as well. "Continually rethinking the scope of practice of emergency physicians is a healthy thing to do," says Pimentel, noting that many emergency medicine groups have already expanded into observation medicine, which is a market that is on the increase.
Another idea that some groups have floated involves providing needed follow-up care to patients who have been discharged from the ED. "The goal of this would be to not necessarily have to admit patients who are borderline [cases] because they would have access to expedited follow-up care," says Pimentel.
The types of patients who might benefit from such follow-up include people who present with high blood glucose levels or who require more intensive management of their blood pressure levels, or patients with infections that are on the border of requiring IV antibiotics and admission versus outpatient care. "If we can provide rapid follow-up so we can be very comfortable that they are going to be seen in 24 to 48 hours, then it might increase our comfort level in discharging some of these patients rather than admitting them," says Pimentel.
