The Emergency Department And Its Effects On Health Care Access

A visit to the emergency department (ED) is usually associated with negative thoughts by most people. It creates preconceived images of overcrowded waiting rooms and routine long waits for treatment (Jarousse, 2011). From 1996 to 2006, ED visits increased annually from 90.3 million to 119.2 million (32% increase). During this same time period, the number of EDs has declined by 186 facilities creating the age old lower supply and greater demand concept (Crane & Noon, 2011). There are many contributing factors that have led to an increase in ED visits. A few of these key drivers include lack of primary care access, rising of the uninsured population, dwindling mental health services, and the growing elderly

S (situation): Hi, my name Kelsey and I am a nurse in the emergency department. I am calling about Shannon O’Reilly’s most recent laboratory results.

Many uninsured and underinsured focus group participants described going to emergency departments for non‐urgent care because they could not afford to pay for private care and knew they would not have to pay the emergency department charges and/or preferred to be seen as soon as possible. Several informants mentioned that the emergency department becomes a default source of primary care, which is costly and lacks the continuity of care that chronic conditions demand ("Community Health Needs Assessment,"

Emergency room over utilization is one of the leading causes of today’s ever increasing healthcare costs. The majority of the patients seen in emergency rooms across the nation are Medicaid recipients, for non-emergent reasons. The federal government initiated Medicaid Managed Care programs to offer better healthcare delivery, adequately compensate providers and reduce healthcare costs. Has Medicaid Managed Care addressed the issues and solved the problem? The answer is ‘Yes’ and ‘No’.

Additionally, urgent care centers have been able to offer patients an alternative to the significantly higher cost of emergency room visits. Following an emergency room visit, patients are charged according to the level of care they are receiving which is rated from minor to major injuries and illnesses. Insurance companies may reject coverage of patients who sought care for a low level injury or illness in an emergency room setting leaving the patient with a large bill for a moderate condition. In addition to the cost of the treatment, insurance companies charge patients an additional fee just for utilizing an emergency room. Furthermore, the cost of seeing an urgent care provider versus an emergency department provider is significantly cheaper.

Access to care has become a buzz word in the modern healthcare theater. The prevailing thought is that our healthcare system will experience a significant amount strain as an increasing number of individuals seek care with increased number of individuals being covered by third party payers under the affordable care act. Access to care has become a catch-all term used to describe the inability for an individual or population to seek needed healthcare services. Access to care can be divided into 4 major problems within a healthcare setting to include, physical accessibility, affordability, acceptability, and supply and demand. While the current state of our healthcare delivery system in regards to the changes implemented by the affordable care act has attempted to address affordability and acceptability. The affordable care act may have strained the infrastructure of our system in regards to the supply and demand aspects as well as physical accessibility challenges to many populations.

One of the primary goals of the Affordable Care Act (ACA) was to provide affordable health care coverage and increase access to affordable health care to the community. Unfortunately, since the passage of the ACA, while there has been an increase in the number of people with health care coverage, those same people do not necessarily have access to affordable health care. Currently, the public views the Emergency Department (ED) as a safety net by the community it serves; as demonstrated by the increasing number of people who continue to seek treatment in the ED for non-urgent problems. Utilization of the ED for non-urgent care contributes to the rising costs of healthcare as treatment in this setting can be upwards of three times the cost

One of the contributors to the rising cost of Healthcare can be attributed to the over use of emergency departments (EDs) for non-emergency needs. In the greater Capitol/First/Beacon Hill area there are three major hospitals (Virginia Mason, Harborview, and Swedish) with emergency rooms and no urgent care centers with the exception of Group Health which is restricted to Group Health insurance members.

Implications on Healthcare System: The general misuse of the Emergency Rooms as a replacement for patient’s primary care can be considered one reason why hospitals on Marcus Island represent the biggest hurdle with regards to healthcare cost containment. Patients are likely to use the ER for primary care because they know they will be seen on the same day at the ER, versus the potential wait time of 2-4 weeks to get an appointment to see their primary care provider. Inappropriate ER use is expensive for hospitals, and prohibits continuity of care for patients.

The Camden Coalition of Healthcare Providers is built on a partnership between with active participation from 3 Camden hospitals, 2 Federally Qualified Healthcare centers, private community-based medical practices, social service agencies and the patients and community at large (Miller, Cunningham, & Ali, 2013). The main goals are improving care for “super-utilizers” while bending the cost curve (Miller et al., 2013). A “super-utilizer” is a person who overuses emergency departments and hospital inpatient services, making more visits to those facilities in a month than some people make in a lifetime (Camden Coalition of Healthcare Providers [CCHP], 2015). Also referred to as “frequent users” or “frequent

Lack of covered care leads the uninsured to local emergency rooms for varied health concerns. This issue will end up weakening the quality of care needed by individuals who are actually in need of emergency care because the care centers may become over populated and under staffed. In the US, there are fewer physicians per person than in most other OECD (Organization for Economic Co-operation and Development) countries. A statement in an article written on PBS’ website, states “In 2010…the U.S. had 2.4 practicing physicians per 1,000 people- well below the OECD average of 3.1.”. Facts like these are quite unsettling, considering tax dollars are still being spent on high medical costs.

In 2014, the Affordable Care Act expanded to make Medicaid available to more adults that live under the poverty line. A survey completed in 2010 showed that an estimated eighty-one million adults were underinsured or completely uninsured during that year (Schoen, Doty, Robertson, and Collins, 2011). The Emergency Medical

434. Paradoxically, the Emergency Medical Treatment and Labor Act (EMTALA) requires Medicare funded hospitals provide appropriate medical treatment for individuals seeking emergency care independent of citizenship, legal status or ability to pay (Rhodes & Smith, 2016). Emergency care is costly and does not address the root cause of disease, furthermore, preventative screenings or health care is not covered under the law (Groppe, 2017). Hospitals must shift cost of providing care to the uninsured emergency care to insured individuals. Researchers in Michigan found with expanded health insurance decreased emergency room visits by 50%. Conversely, in Tennessee and Missouri had an increase in ER costs after cutting Medicaid services in 2015 (Groppe, 2017). The evidence presented suggests providing affordable health insurance for residents of the United States which is independent of citizenship could save money by reducing the need and utilization of emergency care. My follow up question is: Can law makers shift their thinking to provide residents of the country with health insurance in order to save

Tang N, Stein J, Hsia RY et al: Trends and characteristics and US emergency department visits, 1997 – 2007.  JAMA 2010; 304: 664-670

The emergency room has become the new primary care facility for the millions of uninsured in the United States. Thanks to an “unfunded mandate passed into law in 1986,” hospitals that participate in the Medicare program must “screen and treat anyone with an emergency medical condition” (Stephens & Ledlow, 2010). This unfortunately leads to emergency rooms full of people who may have something as simple as a sinus infection which then makes it really difficult for someone with a real emergency that did not require ambulatory transport to be seen in a timely manner. Another unfortunate result of this is that “over 1,100 emergency departments closed over the past decade” (Stephens & Ledlow, 2010).