A March 2015 report from the American Hospital Association, “Always There, Ready to Care: The 24/7 Role of America’s Hospitals,” looks at the increasingly important role of America’s emergency departments in providing healthcare to our country. Drawing from a variety of recent studies and reports, the AHA report focuses on three key roles played by EDs—24-hour access, the safety-net, disaster readiness and response—and the challenges of maintaining their standby role.
24/7 Access to Care
Despite predictions of reduced dependence on EDs under the Patient Protection and Affordable Care Act, most Americans still rely heavily on the 24-hour emergency care provided by hospitals. And the need continues to grow rather than shrink.
Consider these stats:
- An average of 366,000 people seek medical care in the hospital ED each day.
- ED visits have increased by nearly 19 percent over the past decade. In 2013, there were more than 133 million ED visits.
- Almost half (44 percent) of hospital care begins in the ED.
- The majority of ED patients require immediate care: 35.5 percent are semi-urgent (should be seen in 61-120 minutes), 42.3 percent are urgent (should be seen in 15-60 minutes), and 10.7 percent are emergent (should be seen in less than 15 minutes).
As well, individuals suffering from mental health and substance abuse are increasingly relying on hospital EDs for care. Behavioral health-related ED visits rose by 13 percent from 2005 to 2012.
Safety Net Role
The increases in ED visits have been driven by several factors, including an increase in the number of Medicaid beneficiaries and uninsured populations, rising levels of chronic disease, and an aging US population. If ED visits continue to grow at current rate, however, by 2020 hospitals will be treating an additional 29 million individuals.
With no “medical home,” Medicaid beneficiaries and people without health insurance disproportionately use the hospital ED to access care. As more states expand Medicaid under the ACA, those rates could go up even higher since Medicaid beneficiaries are 2.6 times more likely to visit the ED than privately insured individuals. People with no insurance are 1.3 times more likely to visit an ED. Those visits often result in unpaid or underpaid services, however, and in 2013, hospitals provided $46.4 billion in care for which they received no compensation.
Disaster Readiness and Response
The unpredictable nature and timing of disasters requires full-service hospitals to be capable of responding to a variety of potential events at all times. Resources that may go unused for weeks or months or even years must be maintained and ready to go at a moment’s notice to respond to natural disasters, mass crime, and public health crises.
Preparing for and maintaining resources to be used in disasters come with a high price tag.
Challenges
With increased demand for services, along with the mandate to provide 24/7 access, reduced or free care to vulnerable populations, and crisis readiness, hospital emergency departments face extraordinary financial and clinical challenges:
- While ED visits have risen, the number of hospitals providing emergency care has declined.
- Hospitals face a projected need for nearly 900,000 additional caregivers and other staff between now and 2020.
- Hospitals’ standby role is not directly funded; instead those costs are built into the overall cost structure and supported by revenues received from providing direct patient care.
- The ability to generate sufficient funds from patient care to support this role is increasingly at risk: 1.) government payers do not cover the cost of care for Medicare and Medicaid beneficiaries; 2.) despite the unique role played by hospitals and the associated costs, policymakers have proposed cutting payments for certain outpatient services to equal the amount paid in physician offices; 3.) hospitals increasingly are losing patients receiving favorably reimbursed elective diagnostic and surgical care to physician offices, limited-service hospitals, and ambulatory surgery centers. Revenues from those elective services often are used to fund the standby role of hospitals.
The AHA and other industry leaders are asking the following questions about funding and staffing hospitals to provide the access and preparation necessary to meet growing demand in the ED:
- How will financing mechanisms that support the standby role be designed in the future?
- How can the standby role be financed in an increasingly competitive healthcare marketplace where payers want to pay the lowest price?
- What is the appropriate role of government in supporting hospital-based disaster preparedness and relief?
- Should all health care facilities be required to support the community’s standby capacity and care needs?
- What steps can be taken to promote greater access to and utilization of primary care among low-income vulnerable populations to improve their health status and reduce the need for ED care?
For more information, review the AHA’s “Always There, Ready to Care: The 24/7 Role of America’s Hospitals.”
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