Keeping the Emergency Department Healthy
For years, emergency departments (EDs) have been used by low income, Medicaid, and non-insured patients for medical care, regardless of whether their symptoms required emergency intervention. And, EDs have been profiled as one of the largest cost centers in health care. With the expansion of insurance coverage to the non-insured, along with the expansion of Medicaid coverage under the Affordable Care Act (ACA), it was expected that costly visits to the emergency department would be reduced as these newly insureds would now visit primary care physicians and clinics.
However, critics of the ACA predicted the opposite; that emergency room visits would increase due to Medicaid expansion and those newly insured who were unfamiliar with moving through the health care system.
Who was right?
According to a recent survey of more than 2,000 emergency physicians by the American College of Emergency Physicians (ACEP), “three-quarters of them reported that emergency department (ED) use experienced a significant increase over last year, a marked increase from a 2014 version of the same poll, in which half of the respondents identified an increase.” The survey found:
- More than one-quarter (28 percent) of those surveyed reported significant increases in all emergency patients since the requirement to have health insurance took effect.
- 56 percent stated the number of Medicaid patients is increasing.
- About 90 percent reported the severity of illness or injury among emergency patients has either increased (44 percent) or remained the same (42 percent).
Since the original Marketplace open enrollment period began in October 2013, among the 49 states reporting both February 2015 enrollment data and data from July-September of 2013, over 11.7 million additional individuals are enrolled in Medicaid and CHIP. This is a 20.3 percent increase over the average monthly enrollment for July through September of 2013. (Connecticut and Maine are not included in this count.)
The ACEP report also stated that ED leaders blame, in part, the increase in ER use on a lack of more appropriate places for non-urgent care patients to receive care. They believe the plans designed by policymakers and health insurance plans to reduce Medicaid patient use of the ER are not working, citing that more than half of providers listed by Medicaid managed care plans could not offer appointments to enrollees, despite the increasing pay to primary care physicians authorized by the ACA. The median wait time was 2 weeks but over one-quarter of providers had wait times of more than a month for an appointment.
Thus, business is up in the ED, but many are concerned that too much of an increase in non-urgent care could be detrimental to the care of those who are critically injured or need immediate emergency care. The increase in patients also puts strains on ED staff trying to accommodate everyone who presents to the ER and more Medicaid patients at lower Medicaid rates, may increase the financial strains on some hospitals and emergency departments.
The Effect of Alternative Payment Models
Perhaps it is too soon to see the promised reduced usage of the emergency room as intended by the ACA. The savior was to be the alternative payment model. APMs are designed to shift payment away from “volume and intensity to moving toward providing a per-case or per-person payment” and to encourage the support of non-ED physicians to take steps to avoid ED utilization and inpatient admissions.
However, some worry that in the future, these APMs may financially harm emergency departments by sending care elsewhere, which could have significant consequences for the quality of emergency care if APMs result in fewer net resources for EDs. 
It is well-known that the emergency room is the best place to handle three important roles in the healthcare system:
- 24/7 care for the sick and injured, particularly critical illness and injury such as trauma, stroke, etc., and they are the only game in town that stays open 24 hours a day,
- Capacity to respond to public health emergencies, disasters and terrorism, and
- Treatment of patients who need acute care regardless of whether they can pay (Emergency departments are required under a federal mandate to treat everyone, regardless of ability to pay).
The first two are natural fits for the ED and should always be available to the public. More than likely, other locations performing medical care would not threaten to take these patients away from the ED. Where the ED could be threatened would be its third role – treatment of patients who need acute care.
In a HealthAffairs report published in 2010, only 42 percent of the 354 million annual visits for acute care—treatment for newly arising health problems—are made to patients’ personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. 
With such a high volume of acute care encounters being performed in EDs, it is not yet clear how these visits will fit into the new payment models. Payment and delivery reform efforts must support needed improvements in acute care while at the same time assuring adequate support for needed urgent care in the ER. However, this would probably mean shifting acute care to primary care providers or community health centers, leaving EDs with fewer resources to care for the more complex patient population.
So far, there are no new payment models that focus on ED care, and only recently has there been mention of plans to broadly address ED-specific quality through new measurement programs. In December 2014, the National Quality Forum (NQF) released Phase 3 of their endorsed measures for Care Coordination, which proposed five new measures that would directly affect care in the emergency room, particularly transition of care to other locations.
For the ER to survive, payment reform must encourage more appropriate ED use, better care coordination, and more effective and efficient care for ED patients without being destructive to the critical emergency care functions that EDs provide to their communities. In doing so, payment reform should consider:
- Reducing demand for ED care without reducing support for critical ED functions,
- Enabling healthcare organizations to support ED providers in their efforts to deliver effective patient care,
- Increasing the efficiency of ED care without placing patients at undue risk.
Without specific ED payment reform models, hospitals and emergency departments are experimenting with alternative ways of providing care in the ED while reducing costs. HealthAffairs Blog recently reported on how three medical centers instituted acute care-focused payment reforms that, so far, have led to improved value and higher quality care for EDs. What the article didn’t address were the financial implications for emergency departments as these reform measures have initially decreased ED visits.
On May 6, the Richard Merkin Initiative on Payment Reform and Clinical Leadership convened medical and health policy experts to examine strategies that reduce ED system inefficiencies while preserving the best features of emergency medicine. One of the segments centered on payment for ED services as they move to policy reforms that support integration and transformation in the acute care setting. The panelists agreed that “financial alignment among payers, providers, and health entities is essential to ensure connectivity and coordination between EDs, specialists, governments, and authorities and that alternative payment models should be used to reimburse physicians as well as for hospitals to reward specialists, primary care clinicians, and emergency physicians for working together.”
One of the ways to do this is for emergency departments and physicians to participate in developing acute care payment model pilots through the Center for Medicare and Medicaid Innovation (CMMI) and private payer initiatives to reward ED providers for the value they provide through the new services and delivery efficiencies.
Analysts say that the trend of rising ED visits across the nation will continue until the newly insured become more familiar with the health care process, there is an increase in primary care providers, and APMs become more prevalent. In the meantime, it will be important for EDs and their physicians to promote their expertise and efficiency in providing and transitioning patient care and being paid appropriately for it, particularly if ED visits begin to decline. ED providers must engage in reform and integrate themselves into the new payment models to ensure they remain healthy.
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 Medicaid & CHIP: February 2015 Monthly Applications, Eligibility Determinations and Enrollment Report, The Centers for Medicare and Medicaid, May 1, 2015 Report.
 American College of Emergency Physicians, “ER Visits Continue to Rise since Implementation of the Affordable Care Act,” May 4, 2015.
 Pines, Jesse M., et al, “Can Payment Reform Improve Emergency Care?,” MedPage, April 28, 2015.
 Pitts, Stephen R., et al, “Where Americans Get Acute Care: Increasingly, It’s Not At Their Doctor’s Office” HealthAffairs, September 2010.