Fiscal Fitness: How States Cope: Reasons for high emergency department use elusive and they are not tied to uninsured
Fiscal Fitness: How States Cope
Reasons for high emergency department use elusive and they are not tied to uninsured
Contrary to popular wisdom, communities with heavy use of hospital emergency departments (EDs) have fewer numbers of uninsured, Hispanic, and noncitizen residents.
A study of ED use by Center for Studying Health System Change senior fellow Peter Cunningham found that visits to EDs increased 26% between 1993 and 2003 to some 114 million visits annually. About one-third of those visits are classified as nonurgent or semi-urgent, suggesting that the care could have been provided in another setting.
"Increases in emergency department use contribute to overcrowding," Mr. Cunningham says, "which can lead to longer waiting times and more ambulance diversions to other facilities. Growing use of the emergency department for nonurgent medical problems can also increase health care costs and negatively affect quality of, continuity of, and patient satisfaction with care."
Explanations that have been offered for the increase in ED use include changes in the population that have increased demand for ED services and health system changes that have constrained capacity of other outpatient care. Increases in the number of uninsured people who lack access to other types of outpatient care also are often cited.
Mr. Cunningham used data from the 2003 Community Tracking Study (CTS) household survey to look at the extent of variation in ED use across communities and how that variation is related to many population and health system characteristics. His study focused specifically on the extent to which high levels of ED use in some communities are related to high levels of uninsurance and Medicaid coverage, as well as high numbers of noncitizen and racial/ethnic minorities, who are known to have reduced access to medical care. He also looked at evidence that greater convenience of ED and outpatient capacity constraints contribute to high levels of ED use in some communities.
Survey respondents were asked to report the number of visits to hospital EDs in the previous 12 months. They also were asked to distinguish between visits that resulted in an inpatient admission and those that did not. (The data analysis excluded visits resulting in an inpatient stay because they are likely to be the least discretionary type of visit and less affected by patients' preferences and health system factors.)
Wide variation across cities
Mr. Cunningham says he found considerable variation in ED use across the 12 CTS case study sites. The average for 2003 was some 32 visits per 100 people for both the United States and large metropolitan areas. This varied from a high of almost 40 visits per 100 in Cleveland to about 21 visits in Orange County, CA.
"Despite popular perceptions, communities with the highest levels of emergency department use did not necessarily have the highest numbers of uninsured, low-income, racial/ethnic minority, or immigrant residents," Mr. Cunningham says. "For example, Cleveland and Boston had the highest emergency department use levels among the 12 CTS sites and some of the lowest uninsurance rates, while Phoenix and Orange County had both low emergency department use and higher-than-average uninsurance rates in 2003. In addition, communities with the lowest emergency department use also tended to have a higher percentage of Hispanics and noncitizens than communities with high emergency department use."
In 2003, according to Mr. Cunningham's analysis, communities with the highest levels of ED use did not typically have population characteristics that are commonly associated with high levels of use. In fact, he says, there was little variation across the four groups of communities on measures of poverty or health insurance coverage. In terms of race/ethnicity, communities with high ED use had a higher percentage of African Americans than low-ED use communities had, although low-use communities had much higher levels of Latinos and noncitizens compared to high-use communities. More consistent with expectations was that communities with low ED use tended to have somewhat higher numbers of children (who use less health care generally) and fewer people with multiple chronic conditions.
Constraints
The analysis also found a correlation between some health system characteristics and levels of ED use. Thus, in 2003, communities with high ED use tended to have greater outpatient capacity constraints than communities with lower use, as indicated by significantly longer average appointment waiting times. While high-use communities also contained more hospital EDs relative to the population than low-use communities had, there were no statistically significant differences in the average distance to the ED between high- and low-use communities. Contrary to expectations, communities with high ED use had greater community health center capacity in 2003 compared to low-use communities, which Mr. Cunningham says could reflect in part the smaller population and lower population density of high-use areas compared to low-use areas.
More consistent with expectations was that low-use communities tended to have a higher percentage of their insured populations enrolled in HMOs in 2003 compared to other communities.
Results dispute popular notions
While insurance, demographic, socioeconomic, and health factors are strongly related to individuals' emergency department use, Mr. Cunningham says, some of the results run contrary to popular perceptions. For example, in 2003 the uninsured had about 16 fewer visits per 100 people on average than Medicaid enrollees, about 20 fewer visits than Medicare enrollees, and roughly similar levels of use compared to privately insured people. Noncitizens had much lower levels of ED use than citizens did (17 fewer visits per 100 people on average) and the difference between poor citizens and noncitizens was almost twice as large.
In terms of racial/ethnic differences, blacks had higher ED use levels than whites and Hispanics did in 2003. More in line with expectations was the higher ED use by poor people compared to other income groups, and higher use by people in fair or poor health and with chronic medical conditions.
Mr. Cunningham says that for communities whose populations have high rates of ED use, it is unclear how much the rates could be reduced by emulating the health care systems in communities with low use rates.
"For example," he says, "efforts to increase insurance coverage in high-use communities may be a viable strategy for increasing access and reducing the amount of uncompensated care in a community, but it will not decrease overall emergency department use both because coverage rates are already slightly higher in high-use communities and because insured people have as much emergency department use as uninsured people have, or even more."
Increasing outpatient capacity may result in some modest reductions in ED visits for high-use communities, and expansions of HMOs and community health centers might help reduce ED use among poor and low-income people, although Mr. Cunningham found that differences in these two factors are not large enough to account for much of the variation in ED use, even among the poor.
Looking at implications of his research for the future, Mr. Cunningham says population increases will contribute to increases in the overall number of ED visits nationally, although projected changes in the population's composition (such as an increase in the number of people of Hispanic origin) are likely to have mixed effects on ED visit levels.
Immigration
"There is much concern that some of the increase will be driven by illegal immigration," Mr. Cunningham says, "which is cited as straining emergency department capacity in some hospitals, especially along the U.S./Mexico border. However, given the very low levels of emergency department use among poor noncitizens in general (many of whom are likely to be undocumented immigrants), it is very unlikely that these highly localized problems with emergency department crowding will affect the nation more generally as the Latino population increases and migrates to other parts of the country."
One potential source of increases in ED visit rates in the future, according to Mr. Cunningham, is high levels of ED use among Medicare beneficiaries and Medicaid enrollees.
"The aging of the population and retirement of the baby-boom generation will greatly increase Medicare enrollment and the proportion of the population who are elderly, who tend to have higher levels of emergency department use compared to other age groups," he says. "Also, continued increases in private insurance costs could result in increases in both Medicaid and other public coverage of nonelderly people, as well as increases in the number of uninsured people. High use of emergency departments in Medicaid likely reflects in part little or no cost-sharing for health services use, and perhaps lack of access to office-based physicians (because of low physician reimbursement rates under Medicaid). Thus, higher levels of emergency department use associated with increased enrollment in public coverage could be offset to some extent by increasing access to office-based physicians, providing inducements to use nonemergency department settings for nonurgent care, and perhaps greater utilization as evidenced by lower emergency department use among poor people enrolled in HMOs."
However, he says, increases in uninsurance rates are not likely to result in net increases in ED visit rates because although the uninsured rely on emergency departments to a greater extent than insured people do, because they lack access to other outpatient care, their actual use of hospital EDs is no greater than that of the privately insured, probably because fear of incurring the entire cost of an ED visit acts as a constraint on how frequently they visit them.
Why is it broken?
American College of Emergency Physicians (ACEP) president Frederick Blum, MD, FACEP, tells State Health Watch it's important to those on the front lines that the true reasons for increases in ED use are known.
"You can't fix something if you don't know why it's broken," he says. "There have been lots of fallacies about the problem, such as that there are a lot of people in emergency departments who don't need to be there. People who use the emergency department inappropriately are not the source of overcrowding."
According to Dr. Blum, because EDs operate with a triage system, those who seek to use the facility inappropriately are likely to have to wait a long time, backing up in waiting rooms but not causing overcrowding in the ED itself.
The principal problem, according to Dr. Blum, is that the primary care system has failed many people, especially those with chronic conditions who don't have access to appropriate medical care.
"There is a mismatch between resources and demand," he says.
While the number of ED visits has increased significantly over the last decade or more, the number of EDs has dropped in the same period, putting even more pressure on the facilities that remain open, Dr. Blum says. The problem is exacerbated, he says, by the nursing shortage and by declining reimbursement rates.
"There aren't many businesses that could succeed with this business model," he says. "It's not a sustainable business model because of the poor reimbursement."
Mr. Blum says there are no simple fixes for the problem and that what has to be done is to chip away at all the varying causes. "It's potentially going to get worse before it gets better," he cautions. "We need to figure out how to fix the physician payment formula. It's hard to see the way out of the wilderness."
ACEP is supporting the Access to Emergency Medical Services Act that would:
- recognize hospital EDs as the backbone of the nation's health care safety net and help offset the costs of uncompensated care;
- provide hospitals with incentives to end boarding of admitting patients in EDs, to help end gridlock and save lives during natural disasters and acts of terrorism;
- extend liability protection to emergency physicians and on-call specialists who provide critical services to uninsured patients.
"Our emergency departments are struggling with the day-to-day demands put on them," Mr. Blum said. "If something isn't done soon to fortify our emergency services, there is a real question about how hospitals would handle another terrorist attack or major public health crisis."
Increased demand
Mr. Cunningham's analysis indicates that continued increases in ED use nationally are more likely to be driven by increased demand for health care in general than by changes in the population, as was the case with the increase in ED use over the past decade. If increases in the number of physicians aren't able to meet the increased demand, ED visit levels among the population could also increase, he says, as they absorb the overflow of patients who can't get timely appointments with their regular physicians.
Reducing use of hospital EDs for nonurgent medical problems is desirable, according to Mr. Cunningham, because it could help lower overall health care costs and improve patients' experiences with the health care system. However, he cautions, reducing ED use defies simple solutions such as expanding insurance coverage or restricting access for undocumented immigrants.
"Increasing nonemergency department capacity in the health care system, as well as expanding the availability of community health centers and HMOs for low-income people, might lead to some marginal reductions in emergency department use," he says. "Nevertheless, while reducing emergency department use might be desirable from a health system perspective, emergency departments are likely to remain highly popular and convenient sources of medical care for many people and communities, including the majority of emergency department users who have private insurance coverage."
Download an abstract of Mr. Cunningham's analysis from www.healthaffairs.org. E-mail Mr. Cunningham at [email protected] or telephone him at (202) 484-4242. Information on ACEP's position on demand for emergency department services and the legislation it supports is at www.acep.org. Contact Dr. Blum at (202) 728-0610.
Contrary to popular wisdom, communities with heavy use of hospital emergency departments (EDs) have fewer numbers of uninsured, Hispanic, and noncitizen residents.Subscribe Now for Access
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