Emergency Physicians Hope to Be Heard in Debate Over Health System Reform

A new government report that once again highlights the overcrowding typically experienced in US emergency departments may help draw the attention of Congress and the President as they debate ways to reform health care delivery.

The report, by the Government Accountability Office (GAO), notes that overcrowding continues to be an issue that results in delays to patients who need urgent care (http://www.gao.gov/new.items/d09347.pdf). In 2006 (the most recent year studied), the average wait for a patient with a dire emergency to see a physician exceeded recommended time frames. Patients classified as requiring immediate care (to be seen in less than 1 minute) waited an average of 28 minutes while those classified as emergent (to be seen within 1-14 minutes) waited an average of 37 minutes.

The GAO went on to say that almost 74% of patients who were classified as requiring immediate care and just over 50% of patients requiring emergent care had waits that exceeded the recommended time frames. These classifications are based on the 5-level emergency severity index of the National Center for Health Statistics recommended by the Emergency Nurses Association.

Nicholas J. Jouriles, MD, president of the American College of Emergency Physicians, in commenting on the GAO report said, “The information in there is not surprising to the nation's emergency physicians, but this is now the government officially saying this is a problem.”

The report was prepared at the request of Sen Max Baucus (D, Mont), chairman of the Senate Finance Committee. Baucus, a key player in the debate over health system reform, said in a statement that the emergency department overcrowding described in the report was “unacceptable.” He went on to say, “But emergency room overcrowding is only one symptom. The entire health care system is sick.” Baucus had requested a similar report from the GAO (http://www.gao.gov/new.items/d03460.pdf) in 2003 when he was the ranking minority member of the Finance Committee.

James G. Adams, MD, professor and chair of the department of emergency medicine at Northwestern University's Feinberg School of Medicine in Chicago hopes the link Baucus made between emergency department overcrowding and health care reform holds.

“The only good way to decrease crowding is to minimize inflow [of patients] and improve throughput and outflow,” Adams said. “To minimize inflow, we can be in synch with health care reform efforts to optimize cost and quality, with incentives to work across the continuum of care from the emergency department, hospital, specialist, and outpatient doctor, as one big team to share information, add value, avoid duplication and redundancy, and coordinate better.”

Raw numbers help explain the overcrowding situation. In 2002, there were about 4900 emergency departments to handle 110.2 million patient visits. By 2006, there were 4800 emergency departments handling 119.2 million visits (http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf). The rate of visits also increased from 34.2 per 100 individuals in 2002 to 40.5 visits per 100 individuals in 2006. Perhaps not surprisingly, the average length of stay in emergency departments increased from 178 minutes in 2001 to 199 minutes in 199; the percentage of visits in which patients left before a medical evaluation also increased during this period from 1.5% to 2%. Metropolitan-based emergency departments, 66% of all US facilities, receive 85% of the patient visits.

The quality of care provided to patients is also affected by emergency department overcrowding. The GAO cited studies showing that increases in the number of patients leaving an emergency department before an evaluation was associated with fewer patients with pneumonia receiving antibiotics within a recommended 4-hour window. Patients boarded in the emergency department for more than 6 hours before being transferred to an intensive care unit had a rate of in-hospital mortality that was almost 5% higher than that of those boarded for less than 6 hours.

The overcrowding of emergency departments signals that US health care is not delivering on what it promises, said Caroline Steinberg, vice president for trends analysis with the American Hospital Association. “It is a sign of deeper problems with the health care system—a severe workforce shortage, lack of access to capital, rising numbers of uninsured, and financial pressures due to underfunding of Medicare and Medicaid,” Steinberg said.

Adams offered another trend that is affecting emergency care delivery. “Fewer doctors are choosing primary care, and more are specializing,” Adams said. “Both tend to refer to the emergency department cases that require complex workups and lengthy decision making because they have to keep their productivity high to optimize their financial performance.”

An aging population is also adding to the problem. “As patients get older, sicker, more complex; as physicians optimize their efficiency and productivity and specialize narrowly; and as the number of emergency departments in the US slowly declines, crowding occurs,” Adams said. “There is not much to suggest that emergency department crowding will be alleviated.”

Solutions to the problems facing emergency departments seem to center on 2 elements, according to Jouriles and Adams.

The first focuses on developing a medical model that emphasizes continuity of care from primary prevention through posthospital rehabilitation and recuperation. Implementing such a model would involve all elements of the health care system, including the government, health care workers, hospitals, insurers, and public health workers.

The other element involves getting Congress to establish new rules aimed at changing the current system for reimbursement of medical services throughout the health care system, a system that inhibits optimizing quality and positive outcomes. Jouriles, who is also professor of emergency medicine at the Akron General Medical Center and Northeastern Ohio Universities Colleges of Medicine and Pharmacy, said emergency physicians and the services they deliver have always been short-changed by payers.

“One realizes that Congress controls the Centers for Medicare & Medicaid Services, which controls Medicare, and out of Medicare grows the entire health care system,” Jouriles said. “When Medicare came into existence, emergency medicine did not exist as we know it, so emergency medicine has been underpaid since.” He added that private insurers tend to follow Medicare's lead, so the same underfunding and maldistribution of reimbursement turns up when treating privately insured patients.

Putting additional pressures on emergency medicine, Jouriles said, is the Emergency Medical Treatment and Active Labor Act of 1986. This law requires emergency departments and emergency and on-call physicians to provide care to individuals who present and request an examination or treatment for a medical condition; when such persons have an emergency medical condition, they are to be treated until stabilized or transferred to another hospital. “So we are giving away free care, and that number is huge,” Jouriles said. “In 2001, each emergency physician gave $100 000 in free care, and hospitals provided millions of dollars in free services.” The government requires it but does not pay a single penny for it, he added.

Jouriles said the financial pressures burdening emergency departments have broader implications because the root causes will require redistributing health care dollars to maximize efficiencies, quality, and outcomes. “This affects every physician and our job as emergency physicians is to educate the entire physician community about the problem” Jouriles said. “But I also think the physicians in this country feel health reform needs to come, and we need to rethink how we provide care and use resources, and we need to fund it appropriately.”

Although Adams generally agrees with Jouriles, he noted it may be a tough sell in convincing other physicians to work together for the general good of the profession and the health care system. “Currently, each doctor tries to maximize his or her individual efficiency, but that just shifts work elsewhere—say from a specialist's or primary doctor's office to the emergency department,” Adams said. “But since we are paid per encounter, per procedure, rather than for larger outcomes, we don't coordinate and communicate; we repeat tests, start evaluations from scratch, and do a lot of work that does not contribute to optimal outcomes. The incentives for broad communication, streamlined care, and systemwide efficiency are less immediate and clear.”

Steinberg said some revamping of emergency care delivery can be done at a local level but that its high costs and need to coordinate with neighboring communities requires rules and goals being set by higher authorities. “Care coordination certainly starts at the practitioner level,” he said. “But then the incentives in the system currently do not provide for care coordination, so the establishment of a structure in which care coordination can occur is a state or federal responsibility.”

Jouriles hopes that the GAO report and its enthusiastic reception by Sen Baucus will increase the likelihood that emergency medicine will have a place at the table among those debating health care reform. “Health reform discussions have so far not included emergency care,” he said. “And unless we address emergency care, our nation is in trouble.”