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Emergency Medicine Clinics Of North America

ABSTRACT

In the US health care system, a core safety net provider has two defining characteristics: (1) either by legal mandate or explicitly adopted mission, they maintain an "open door," offering patients services regardless of their ability to pay; and (2) a substantial portion of their patients are uninsured, on Medicaid, and/or otherwise vulnerable. The hospital Emergency Department (ED), by all accounts, falls within the definition of a core safety net provider. Yet many would argue that this is a primary health care role for which the ED was not originally intended or equipped. Should the ED be society's health-care safety net? Should it be the main provider of care for the indigent? Is this placing an unbearable strain on the ED? Should it be providing primary health-care? If not, what are the alternatives?

Journal of Public Health Policy (2005) 26, 269-281.

doi:10.1057/palgrave.jphp.3200028

Keywords: safety net, emergency department, Medicaid, Emergency Medical Treatment and Labor Act (EMTALA)

INTRODUCTION

The United States (US) health-care system consists of a diverse network of components including federal (national) and state government agencies, as well as independent and private agencies. American health care is largely delivered in a well-established free enterprise system. Insurance is the main method of financing health care, and this is usually administered by private companies. Government assistance, in the form of the Medicaid program, is available from each state for people receiving welfare (grants to certain poor people), to pregnant women, children, and those with disabilities. The Medicare program performs a similar function for the elderly and disabled who are eligible. Many Americans, however, do not qualify for government assistance and are unable to afford health insurance. These "uninsured" (age

Services for the uninsured have been called a health-care "safety net", able to provide medical care for those who fall through the gaps in the health-care system. Again, this is a diverse collection of government, local and voluntary providers who offer various services. In zooo, the Institute of Medicine, National Academy of Sciences (IOM) published a report entitled America's Health Care Safety Net: Intact but Endangered (z). In it, the IOM committee said core safety net providers had two defining characteristics: (i) either by legal mandate or explicitly adopted mission they maintain an "open door", offering access to services for patients regardless of their ability to pay; and (z) a substantial share of their patient mix is uninsured, Medicaid, and/or other vulnerable patients. Although the report did not specifically address Emergency Departments (ED), by all accounts, the ED falls into this definition of a core safety net provider. Yet many would argue that the health safety net is a primary health-care role for which the ED was not originally intended or equipped (3). American society and government have also been slow to acknowledge this role, and its financial implications (4).

Some suggest that the ED is the only federally mandated safety net in America (5). The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, extends a civil right to all US residents (6). This law requires screening and stabilization for all who seek emergency medical care, regardless of their ability to pay. It threatens both physicians and hospitals with legal and financial penalties for non-compliance (4). Yet there is budget for the uncompensated care that it engenders (7).

Observers have also noted with despair the unravelling of the other components of the US health-care safety net - public health clinics, free clinics, and "public hospitals" (5). The number of uninsured US residents is estimated to exceed 42 million, and the number is growing (8). For many vulnerable and disenfranchised populations, the ED may be the only available access to care (9). Inadequate or inaccessible primary care is frequently cited in studies as the most common reason for ED visits, irrespective of the urgency of the medical problem (10,11).

Hospital capacities have continued to shrink due to restructuring, leading to ED crowding and ambulance diversions - an emerging threat to patient safety and public health (12). Worsening since 1990 (13), crowded conditions in the ED have been blamed for some patient deaths (14). In Arizona, where it has reached a critical state, the state's College of Emergency Physicians lost confidence in the emergency health-care infrastructure and issued a statement that current resources supporting emergency care were inadequate to meet the needs of all patients at all times (15). This is not a unique experience but a national one (14,16,17).

Thus, a review of this issue is timely. Should the ED be society's health-care safety net? Should it be the main provider of care for the poor and needy? Is this placing an unbearable strain on the ED? Should it be providing primary health care? What are the alternatives?

OVERVIEW OF ISSUE

The functions of the ED in North America has evolved over the past 30 years as Emergency Medicine (EM) outgrew its one room in the hospital (the "Emergency Room") to become a new specialty with more than ioo residency training programs (18). Today EM represents a special body of knowledge including the science of resuscitation (19) and management of acute trauma, illness, and critical conditions. The ED provides continuous, round-the-clock availability of concentrated diagnostic and therapeutic services. In many hospitals, it also serves as the entry for most patients with acute medical and surgical conditions.

The availability of the ED after practitioner office hours contributed to its use by patients and physicians as a back-up for primary care providers (2.0,2.1). Perceived ease of access results in a large number of patients with "non-acute" conditions presenting daily at the ED. This is especially true for the disenfranchised, with limited or no access to primary health care (4). This is underscored by the fact that there are only 1,000 federally chartered non-profit clinics (8) in the US. Under welfare reform initiated during the Reagan administration, the government has reduced food assistance, welfare payments, disability income, and health insurance, with one exception: " No state may deny coverage of emergency medical services to either illegal or legal aliens" (22). Thus, the ED is singled out by legislation as the only component of the entire social welfare system that is protected by law for the most disadvantaged. Although the ED is not traditionally viewed as a major social welfare institution, this role seems enshrined in federal law.

Since 1958, the number of ED visits in the US has increased more than 600% to an estimated 108 million ED visits in 2000 (2.3). Yet between 1994 and 2001, 546 EDs were closed (7) and the American Hospital Association reports the number of in-patient beds has decreased 39% between 1981 and 1999 (12). Thus we have a crisis of overcrowding in the ED. An aging population and an increasing prevalence of complex medical problems has increased the severity of illness among ED patients (24). The number of critically ill patients in California EDs increased by 59% from 1990 to 1999 (25).

Hospital system restructuring since the 1980's - hospital closures and in-patient downsizing - has further contributed to ED crowding, driven as it is by cost containment, managed care and a shift in emphasis from in-patient to outpatient care. Elimination of EDs by mergers and closures increases the burden on neighboring EDs (12), an effect reported in Canada as well (26). In the current payment climate, hospital managers are increasingly willing to divest, close, or downsize hospital departments that fail to cover their costs. The ED appears to be a financial weak link, because indigent patients and Medicaid patients whose payments do not cover costs appear at the ED. If the hospital closes its ED, it reduces those financial losses (7).

To complete this picture, qualified emergency physicians (27) are in short supply, ED nurses more so, with vacancy rates in some states as high as 18% (28). Fewer medical and surgical sub-specialists are willing or available to provide consultative backup to the ED (29-31), perhaps related to poor payment for mandated emergency services and increasing liability (malpractice) insurance premiums for ED physicians and those providing trauma on-call services (23).

From an international perspective, the problem of ED crowding is not limited to the US. Similar problems are linked to inadequate inpatient bed availability in the United Kingdom (32), Canada (26) and Australia (33). ED crowding is now recognized as an international symptom of health-care system failure (34).

What are the effects of ED crowding? The most worrying effect is that it compromises quality of care and may lead to medical errors, poor outcomes, and even unnecessary patient deaths (35). In many cases, EDs are forced to use hallways and other improvised, poorly equipped locations as treatment areas, negatively affecting patient comfort, care satisfaction, confidentiality, and risk for errors (23). The only way busy clinicians faced with too many patients can care for all is to spend less time with each patient. Lengthy waiting times mean prolonged pain and suffering for patients and a risk that their condition may deteriorate while waiting to be seen. For ED staff, the high-stress environment contributes to staff burnout, higher turnover rates, worsens deficiencies in staffing and impairs ongoing clinical teaching (24).

The other prominent adverse effect is ambulance diversion. Ambulance diversion occurs when ambulances are unable to deliver patients to their usual, appropriate EDs because these EDs are overloaded. They are then "diverted" to the next available ED. Ambulance diversion is now a common, year long occurrence affecting more than two thirds of US hospitals in urban, suburban, and rural settings (36,37). Timely emergency care requires rapid ambulance transport, thus diverting ambulances because of ED crowding delays crucial treatment. Numerous hospitals in the same city may be on diversion simultaneously, resulting in "ambulance gridlock". This failure of the health safety net affects people of all social and economic strata (2.3).

Short supply of in-patient beds has also resulted in "boarding" when EDs are forced to hold patients for several hours, as many as 24, until an in-patient bed becomes unavailable (35,38). Boarding causes the ED to be filled beyond capacity with the most acutely ill and injured patients. EDs have not been designed, equipped, or staffed to give severely ill patients undivided attention over long periods of time. Boarding patients may, moreover, be so labor intensive that other patients may not be receive necessary attention from ED staff (12).

September 11, 2001 highlighted the need for disaster preparedness. A key component of disaster/terrorism response is ED readiness (39). A system struggling to handle its daily load will be overwhelmed in a disaster - a powerful argument for surge capacity to manage disaster-related increases in patients. We must address the root causes of overcrowding, as conditions are predicted to get worse if unresolved (13).

APPROACHES TO THE ISSUES

Should the ED be society's health safety net? If we say yes, are we providing it with the societal resources needed to fulfill this welfare function? If we say no, what is the alternative? Whose responsibility should it be? Are we in the US prepared for radical health-care reform?

American health care is largely delivered in a free enterprise system, and as in true free markets, health care is available increasingly only to those who can pay (40). One might make the moral argument that society in general, and government in particular, should not be abdicating its responsibility to hospitals and their EDs in particular (4). This argues for the need to develop alternative safety net providers, and improve access to basic health care, whether by universal health care or other methods.

Obviously the ED cannot be the panacea, offering all access to health care. ED crowding highlights the limitations of its resources (12). Some argue that additional missions for the ED will distract it from its core mission of providing accessible, quality, acute trauma and medical care. They argue for a stronger network of affordable, accessible, primary health-care providers, focusing on prevention, maternal and child services, chronic disease management and wellness. However, only one-third of all practicing US physicians are in primary care - an apparent "oversupply" of specialists (41).

No doubt, the ED is ill suited by its design to provide long-term follow-up and care of chronic conditions: these are better provided by primary care physicians able to provide continuity of care. Not a cost-efficient model for continuity of care, EM training is not focused on delivering chronic care for stable medical conditions like hypertension and diabetes. Highly trained staff, expensive equipment, and administrative overheads can make ED care twice as expensive as comparable care in an office setting (7).

The care of indigent patients often requires a comprehensive system of social screening, evaluation, and service coordination, well beyond the traditional scope of the ED (42.). In its current form, the ED often remains unable to connect to community and social resources these patients often need.

Fiscal problems also argue against continuation of the current situation. In 1991, uninsured patients received an estimated $15.2 billion in care for which hospitals were not paid (4), an amount then predicted to grow to $zy.6 billion by 1995. Separately, public data suggested in 1996 that the total direct expense for Emergency Physician (EP) services to the uninsured was approximately $i billion annually (43). Such a situation cannot be sustained for long, yet for every ED that closes and every EP who is unwilling or unable to continue to provide services, the burden falls more heavily on those who remain.

There are, however, dangers in denying or downplaying the role of the ED in the health-care safety net. In Canada with universal government-sponsored health insurance, ED visits continued to increase rapidly rather than decrease (44,45). Nor has managed care been able to fulfill its promise of reducing ED visits (46). Nor did improved primary care access eliminate preference for ED use among disadvantaged children (47).

During the 19905, EDs tried to identify "inappropriate" visits, and to triage away (48) or use gatekeepers (3) to restrict access. Risks associated with denying emergency care and more sophisticated analysis of costs have lead to a reconsideration of these efforts (48). Under current reimbursement schemes, moreover EDs could not survive financially if they cared for only truly urgent cases (18). EDs depend on cost-shifting onto a high volume of less urgent, "profitable" patients to cover their costs and remain available for the fewer, "money losing" critical emergencies.

Will health-care reform efforts decrease the supply of EPs? The Council of Graduate Medical Education (COGME), which oversees specialty medical training in the US, has recommended shifting GME training positions toward primary care away from specialties (49). EM has been labelled by organized medicine as a support specialty (50), despite its role in primary care. COGME has not studied EM as a primary care specialty, nor analyzed EM as a shortage specialty, despite evidence of a shortage of EPs (18).

Should the ED then be considered as a true safety net institution? The strongest argument is the legal mandate in EMTALA (4). The ED is obliged never to turn away patients with true needs in an emergency - a moral argument. The ED is a vital community resource, providing 2,4/7 access to medical care and with the potential of being a vital link to integrated resources (42), thus the argument that ED overuse leads to high medical care costs may also be overstated (48). The ED has high fixed costs (costs that are not dependent on volume) and very low marginal costs (the additional cost for additional visits). Thus, the diversion of non-urgent visits to private physician's offices may result in fewer monetary savings than believed. Furthermore, redirection of ED patients might require creation of 24-h walk-in primary care centers with similar staff and equipment costs.

What are the implications of assigning a formal safety net role to the ED? The ED needs to be strengthened to fulfill its social welfare function, ensuring that it has sufficient staff and resources. The ED could also serve as a "social triage" center (42) so that patients identified with pressing social needs could be referred for further evaluation and service coordination. ED staff would need training to perform initial evaluations and work closely with social workers and service coordinators. Integration with community safety net providers would ensure follow-up after discharge from the ED (51).

The ED, a window on what is happening in the broader medical care environment can help monitor the health-care safety net. EDs observe the viability of community safety net providers and can provide feedback on the effectiveness of health-care programs. For example, an ED might, detect barriers to enrollment in StateChildren's Health Insurance Programs (S-CHIP) (51), a state level program to provide health insurance coverage to children in the US.

EDs in the safety net role might affect health-care financing. Federal Disproportionate Share Funding (DISH), a reimbursement program for providers of indigent care, currently assists only hospitals and only for in-patient indigent care (5). DISH could be restructured to cover outpatient care as well and to compensate physician providers of uncompensated care. Cumbersome Medicaid reimbursement procedures could be simplified for EDs. Medicare/ Medicaid funding could be restructured to provide incentives for after-hours emergency care to alleviate on-call physician shortage (5). Staff and nursing shortages must be addressed.

We believe consideration should also be given to funding EDs as a "community essential" service, placing EDs on a similar status as other essential services like fire, police and Emergency Medical Services (EMS or ambulance) partly because of their crucial role in the Homeland security Emergency Preparedness.

Either radical health-care reform or strengthening the ED safety net, requires social consensus and considerable resources and effort. We face the danger of paralysis, allowing current conditions to deteriorate.

CONCLUSION

In the US, the ED has a mandated role as society's health safety net of last resort, but this does not mean that it is properly equipped to fulfill this role, or that it should be the answer to problems of access to health care. A pragmatic approach might be to recognize the EDs safety net role and strengthen it to fulfill the role, addressing shortages in facilities and staff and improving reimbursement and financial incentives. Integrating the ED in a community safety network would let it function both as an entry point and as a monitor.

In the long term, the issue is only the symptom of a larger underlying problem, access to health care. A solution can only come with improving access to health care, an emphasis on prevention and primary health services.

The issues here also have relevance for many countries dealing with ED crowding and problems of access to health care. Those with significant private sector health care, or countries experimenting with health-care privatization would do well to consider these issues.

Meanwhile, several trends in the US will continue to influence the future of EDs: the increasing number of uninsured patients (48) and the on-going consolidation and restructuring of the health-care industry (7); increased demand on the ED in emergency preparedness and disaster/terrorism planning (52,53). Finally, it remains to be seen whether there will be health care reform in the US and how it will impact the ED (18).

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MARCUS ONG ENG HOCK*, JOSEPH P. ORNATO, COURTNEY COSBY and THOMAS FRANCK

* Address for Correspondence: c/o Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore. E-mail: gaeoeh@sgh.com.sg

MARCUS ONG ENG HOCK, M.D., F.R.C.S. ED (A&E) is in the Department of Emergency Medicine, Virginia Commonwealth University Medical Center, 401 North izth Street, PO Box 980401, Richmond, VA 2^98-8597, USA. mftjong@yahoo.com

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