The Emergency Department’s Role is Critical

How much does the emergency department contribute to healthcare delivery in the United States? Do our policies reflect the emergency department’s current role?

This study assessed the contribution of emergency departments to the health care received in the United States compared to that of outpatient and inpatient services from 1996 to 2010. Using data from two nationally representative samples, the authors found that emergency departments accounted for 47.7% of nonfederal hospital-associated medical care, with that percentage steadily increasing over the study period.

Populations found to account for the increase in emergency department utilization included: Blacks, Medicare and Medicaid recipients, women, and residents of the South and the West. This finding points to the emergency department’s unique role in providing care to the most socioeconomic vulnerable of Americans and filling the gap in access to care. In a time of turbulent healthcare reform when accessibility and affordability are often in flux, emergency care continues to have an essential role in our country’s healthcare system.

Despite its important role, current models of healthcare delivery – including patient-centered medical homes and accountable care organizations – often fail to consider the full extent of the emergency department’s contribution. The authors discuss the emergency department’s controversial role in treatment of nonemergency cases. Nonemergent care utilization is often cost-ineffective and a poor use of resources. However, given that many populations who seek the emergency department for nonemergent conditions do so because of limited options for other care, denying these patients treatment would be uncompassionate. The emergency department must play a role in improving how vulnerable populations receive care, yet this approach should be better integrated with outpatient systems and resources.

Since Medicaid expansion under the Affordable Care Act, evidence suggests that the utilization of the emergency department has actually increased. Assuming these trends continue, future healthcare reform must remain cognizant of the emergency department’s large contribution to the overall system. Current efforts to discourage the use of the emergency department for nonemergent care through coverage denial is a dangerous exercise that only exacerbates barriers to access care. Policies should not seek to curb emergency department usage, but instead to include it as a coordinated component of healthcare delivery models.

This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. It is written by Elizabeth Sherrill Bermudez. She is an emergency medicine resident at Vanderbilt Medical Center.

Abstract

Traditional approaches to assessing the health of populations focus on the use of primary care and the delivery of care through patient-centered homes, managed care resources, and accountable care organizations. The use of emergency departments (EDs) has largely not been given consideration in these models. Our study aimed to determine the contribution of EDs to the health care received by Americans between 1996 and 2010 and to compare it with the contribution of outpatient and inpatient services using National Hospital Ambulatory Medical Care Survey and National Hospital Discharge Survey databases. We found that EDs contributed an average of 47.7% of the hospital-associated medical care delivered in the United States, and this percentage increased steadily over the 14-year study period. EDs are a major source of medical care in the United States, especially for vulnerable populations, and this contribution increased throughout the study period. Including emergency care within health reform and population health efforts would prove valuable to supporting the health of the nation.

PMID: 29039720 

Marcozzi, D, et al. Int J Health Serv. 2018; 48 (2): 267-288.