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Subject: qotd: Evolving Role of Emergency Departments
Date: Tue, 21 May 2013 11:01:13 -0700
From: Don McCanne <firstname.lastname@example.org>
To: Quote-of-the-Day <email@example.com>
May 20, 2013
The Evolving Role of Emergency Departments in the United States
By Kristy Gonzalez Morganti, Sebastian Bauhoff, Janice C. Blanchard,
Mahshid Abir, Neema Iyer, Alexandria Smith, Joseph V. Vesely, Edward
Okeke, Arthur L. Kellermann
To develop a more complete picture of how EDs (emergency departments)
contribute to our modern health care system, the Emergency Medicine
Action Fund asked RAND to conduct this mixed-methods study.
Key findings include the following:
• Between 2003 and 2009, inpatient admissions to U.S. hospitals grew at
a slower rate than the population overall. However, nearly all of the
growth in admissions was due to a 17 percent increase in unscheduled
inpatient admissions from EDs. This growth in ED admissions more than
offset a 10 percent decrease in admissions from doctors' offices and
other outpatient settings. This pattern suggests that office-based
physicians are directing to EDs some of the patients they previously
admitted to the hospital.
• In addition to serving as an increasingly important portal of hospital
admissions, EDs support primary care practices by performing complex
diagnostic workups and handling overflow, after-hours, and weekend
demand for care. Almost all of the physicians we interviewed—specialist
and primary care alike—confirmed that office-based physicians
increasingly rely on EDs to evaluate complex patients with potentially
serious problems, rather than managing these patient themselves.
• As a result of these shifts in practice, emergency physicians are
increasingly serving as the major decisionmaker for approximately half
of all hospital admissions in the United States. This role has important
financial implications, not only because admissions generate the bulk of
facility revenue for hospitals, but also because inpatient care accounts
for 31 percent of national health care spending.
• Although the core role of EDs is to evaluate and stabilize seriously
ill and injured patients, the vast majority of patients who seek care in
an ED walk in the front door and leave the same way. Data from the
Community Tracking Study indicate that most ambulatory patients do not
use EDs for the sake of convenience. Rather, they seek care in EDs
because they perceive no viable alternative exists, or because a health
care provider sent them there.
• Medicare accounts for more inpatient admissions from EDs than any
other payer. To gain insight into whether care coordination makes a
difference in the likelihood of hospital admission from an ED, we
compared ED admission rates among Medicare beneficiaries enrolled in a
Medicare Choice plan versus beneficiaries enrolled in Medicare
fee-for-service (FFS). We found no clear effect on inpatient admissions
overall, or on a subset of admissions involving conditions that might be
considered "judgment calls."
• Irrespective of the impact of care coordination, EDs may be playing a
constructive role in constraining the growth of inpatient admissions.
Although the number of non-elective ED admissions has increased
substantially over the past decade, inpatient admissions of ED patients
with "potentially preventable admissions" (as defined by the Agency for
Healthcare Research and Quality) are flat over this time interval.
Our study indicates that: (1) EDs have become an important source of
admissions for American hospitals; (2) EDs are being used with
increasing frequency to conduct complex diagnostic workups of patients
with worrisome symptoms; (3) Despite recent efforts to strengthen
primary care, the principal reason patients visit EDs for non-emergent
outpatient care is lack of timely options elsewhere; and (4) EDs may be
playing a constructive role in preventing some hospital admissions,
particularly those involving patients with an ambulatory care sensitive
condition. Policymakers, third party payers, and the public should be
aware of the various ways EDs meet the health care needs of the
communities they serve and support the efforts of ED providers to more
effectively integrate ED operations into both inpatient and outpatient
Comment: This RAND Health report provides an excellent perspective on
how emergency departments (EDs) have evolved into institutions providing
a greater central role in health care delivery. It is a particularly
valuable report because it sets aside many misperceptions about ED
functions - misperceptions that can lead to flawed policy recommendations.
It is crucial that we continue to assess and recommend improvements in
the health care delivery system. This report reflects the benefit of
such an approach since EDs have expanded their roles in very beneficial
ways. As they continue to evolve, integration with both inpatient and
outpatient care should become more efficient, especially from the
perspective of benefiting patients.
The current focus of policy reform seems to be not so much on the
improvement of health care delivery, but rather on mechanisms that
supposedly would slow the growth in health care spending. Accountable
care organizations, bundling of payments, innovative insurance designs
such as those that erect financial barriers to care, are the types of
policy approaches that will have very little impact on overall costs
while inappropriately expanding the administrative excesses of our
This report is well worth downloading. As you read it, you can see many
opportunities to further expand the progress that we have seen through
the evolving improvements in the role of EDs in our health care system.
Thinking about how further improvement in integrating their role with
both inpatient and various community outpatient services can help us
envision further opportunities to achieve the goals of a
An example of the misguided and misdirected emphasis on innovative
payment reform is the failure to find any clear effect on inpatient
admissions when comparing the public Medicare program with the much more
expensive private Medicare Advantage plans. Payment innovation is simply
not where it's at.
We need to get this right. Let's continue to work on fixing the health
care delivery system so that it works best for patients. That is the key
to improving value in health care. It will work as long as we adopt a
financing system that is designed exclusively to fund a high-performance
health care system (single payer), as opposed to one that is designed to
keep policy wonks and insurance administrators employed in bringing us
ever-expanding payment innovations that we don't want (Obamacare).