Reform may worsen ER crowding

Associated Press medical reporter Carla K. Johnson has found that, contrary to common assumptions, emergency rooms could become even more crowded with the passage and implementation of health care reform. Popular wisdom has it that, with more access to insurance thus to primary care, folks will be less likely to go to the emergency room for minor complaints or to allow illness to progress to the point where an emergency visit is necessary. Johnson, an AHCJ board member, gives three big reasons why it’s not that simple:

  • There are not (will not) be enough primary care physicians in America to deliver that preventative care.
  • At present, the uninsured are no more likely to use the ER than patients with insurance coverage.
  • “The biggest users of emergency rooms by far are Medicaid recipients,” Johnson writes. “And the new health insurance law will increase their ranks by about 16 million.”

ERs are crowded, Johnson writes, not only because of a lack of insurance but also because of obstacles inherent in their structure and mission, such as an aging population, more people with chronic illnesses, the closures of many ERs in the 1990s and the demand for beds for both emergency patients and patients scheduled for elective surgeries that bring more money.

AHCJ Immediate Past President Trudy Lieberman praised Johnson’s story and linked it to reporting by The Boston Globe on the impact of that state’s reform law upon emergency room use. So far, events in Massachusetts reinforce Johnson’s predictions.

The Boston Globe revisited Massachusetts’s ER conundrum last week, and reported pretty much what it did last year—that despite the state’s reform law, which mandated everyone have coverage beginning in July 2007, emergency room use is rising. Last year, the state’s Division of Health Care Finance and Policy cautioned that it was too early to draw any conclusions from the seven percent rise in ER visits between 2005 and 2007. Now the agency is saying that expanded coverage may be one reason for the 9 percent rise from 2004 to 2008. According to commissioner David Morales, many studies have shown that expanding coverage does not reduce emergency room visits. That’s because the uninsured “are not really responsible for significant ER use,” he told the Globe.

1 thought on “Reform may worsen ER crowding

  1. Avatar photoGienna Shaw

    Healthcare organizations know that they need to spend more time and money on wellness, preventative care and chronic disease management to keep these patients out of the ER. They’re still working out how to do that–especially in the face of a critical physician and specialist shortage. But they are working on it.
    And technology will help.

    One example: Using telehealth technology to monitor patients at home which, the theory goes, lets caregivers intervene faster when a patient shows signs of decline or stops taking his or her meds or complying with other orders, thus keeping him or her out of the ED.

    Another example: eICU monitoring has been shown in recent studies to reduce the number of ICU days, which are much more expensive than non-ICU days and patients who spend less time in intensive care also tend to recover more quickly–opening up beds and freeing up clinicians to care for other patients.

    And telehealth centers that monitor patients remotely take pressure off of physician, specialist, and primary care doctors. Further, remote monitoring and e-visits will allow areas where physician shortages are most acute (such as rural areas) to “beam in” consulting clinicians and improve access.

    Hospitals know that under healthcare reform–and coming changes to reimbursement including bundled payments and payment for quality outcomes rather than for episodes of care–they will have to cut costs, especially in the cost-intensive ED. Further, most healthcare organizations are doing everything they can to reduce readmissions to avoid financial penalties and non-payment by CMS. Again, reducing readmissions frees up beds and clinicians’ time and improves access for those who *supposedly* can’t get care anywhere else.

    This is all driven by the desire to provide better care to patients, of course. But it is also a business imperative.

    When reporters are covering healthcare, they cannot forget that hospitals–even non-profits–are businesses. They will be working to reduce costs, reduce waste, improve efficiency, and at the same time improve quality in the ED and elsewhere along the continuum of care. If they don’t, they won’t stay in business.

    One last thing: That giant sheet of paper that tracks throughput and other goals mentioned in the story? That will likely be replaced by an EMR, funded in part by HITECH stimulus money and prompted by financial penalties for those that do not implement them. The government’s push for Healthcare IT is a game-changer. The first place many hospitals will deploy IT to improve patient flow will be the ED. And the resulting reams of data will help hospitals figure out where, when, and why those bottlenecks occur so that they can make improvements.

    If you want more in-depth information about some of these issues, may I suggest you read HIT That Enables Quality, Efficiency, and Value ( and Medical Breakthroughs that will Change Healthcare ( Jump to the
    the section on wireless technologies (bottom of page one and top of page two).

    I’m not saying ED overcrowding isn’t a problem. I’m just saying that there are more solutions than this article suggests and that hospitals are very motivated to explore and implement them.

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