Emergency Room use Grew to Unprecedented Levels in 2008
The recession has resulted in more people—especially those who are unable to pay for healthcare—going to the emergency room (ER).
“Demand for emergency services continues to show strong signs of growth, especially in the last few years of economic difficulties,” said Wendell Pahls, MD, medical director of emergency services for Baptist Health Medical Center Little Rock. “Demand for emergency services grew from 1990 to 2000 by 15 percent and from 1998 to the year 2008 demand was up by 24 percent. According to one source, the increase in demand for services in the year 2008 was the largest on record.”
There are a multitude of factors that drive patients to seek care in the emergency department (ED) including pain, fear, confusion and economics. Pahls said to adequately address the growing trend of using the ED as a primary care provider will require a coordinated effort on the part of physicians, hospitals/clinics and insurers to both encourage and require patient care to move to a more efficient and cost effective method of delivery.
“The number of uninsured patients has increased noticeably in the past two years,” Pahls said. “There has also been an upward trend in the number of Medicare/Medicaid patients utilizing the EDs for care as it becomes increasingly difficult for private practice physicians to continue to see new patients in this payer mix in their office. This combination has created a tremendous strain on the resources available to care for patients in the EDs. It has also created a significant strain on the available physician manpower to provide call coverage for admission and/or specialty care services.”
Greg Hammons, DO, systems medical director for medical services, St. Vincent Health System, Little Rock, said over utilization and overcrowding of ERs continues to be a front burner issue.
“It is largely due to under-insurance and uninsured patients with decreased access to primary care,” Hammons said. “A lot of patients seen in the past by primary care physicians are coming to the ER now.”
Some hospitals in the country have taken actions to try to stem the overuse of ERs by having a physician’s assistant or nurse practitioner do a medical screening exam. If patients are not deemed to have an urgent medical condition, they are given a couple of options. They are referred to a primary care clinic or asked for an upfront co-pay if they continue to be seen in the ER.
“That is something we haven’t done at St. Vincent,” Hammons said. “We have kicked it around, but right now it does not fit with our mission.”
In 2009, Arkansas hospitals spent almost $400 million providing uncompensated care.
“That includes a combination of bad debt costs and charity care,” said Paul Cunningham, senior vice president, Arkansas Hospital Association. “There’s no breakdown to show how much was related specifically to ED services. However, because of the reasons above related to ER overcrowding and the fact that the hospital ER is one of the most costly settings where hospital care is provided, it is logical to presume that spending in the ER is a major reason why Arkansas hospitals had an operating margin loss of (-2.06 percent) on all patient care services provided that year.”
There is really very little that hospitals can do. Federal law requires that hospitals see all patients who come to their ERs. The Emergency Medical Treatment and Active Labor Act (EMTALA), enacted in 1985, was passed with the intent to protect the rights of indigent patients seeking emergency care.
“It requires all Medicare-participating hospitals – which is all hospitals, practically speaking – to provide a medical screening examination for any patient who presents for care to the ER, regardless of their ability to pay, and specifies that the scope of the exam should include all ancillary services routinely available to ER patients, including inpatient care, if required. In essence, EMTALA has made hospital ERs the single place where all patients are guaranteed medical care 24/7/365.”
There is no circumventing the law without incurring major penalties. Despite its good intentions, EMTALA has created an economic challenge for hospitals, because while it guarantees care in the ER, it does not guarantee reimbursement for the ER care provided, Cunningham said.
Another problem is that people tend to put off care, and then go to the ER. Cunningham said that’s often true even for patients who have insurance, but is even more prevalent among the uninsured and others who don’t have ready access to a primary care provider and who are prone to look to the local ER as the place to go when they or their children have fever, aches, pains and other conditions which could be more efficiently treated in a physician’s office.
In addition to the growing numbers of uninsured people who may see few options to the ER as a place to obtain care, an increase in the numbers of homeless people and a growing population of “heavy users” of ED services who present frequently to ERs looking for pain meds or who go there when in need for mental healthcare contribute to ER backlogs.
“To the extent possible, hospital ER teams triage patients to determine those with the most urgent needs,” Cunningham said. “So, the brain trauma victim will get priority over the patient who has broken arm, who, in turn, gets priority over the one presenting with a fever. But, the overcrowding does take a toll in the form of stress on ER personnel, excessive waiting times to see an ED physician or delays in treatments in the ED and delays in the movement of ER patients who may need to be admitted for general or intensive inpatient care.”