The Evolving Role Of ER Doctors And EDs In Delivery Of Healthcare
Emergency physicians are important decision makers for roughly half of all hospital admissions, underscoring the key role they can play in reducing health care costs, according to a recent study by the RAND Corporation, a nonprofit non governmental organization. Based on recent data from the American College of Emergency Physicians (ACEP), hospital admissions from the emergency department (ED) increased by 17 percent from 2003-2009.
The study also pointed out the fact that hospital inpatient care is a key determinant of overall health care costs and expenditures, comprising 31 percent of US health care costs. The study was commissioned by the Emergency Medicine Action Fund (EMAF), an advocacy group with ACEP, and carried out by the RAND Corporation.
The take-home message is that hospital administrators, insurers and policy makers should place greater focus on the important role that emergency physicians (EP) exert in the process of hospital admission or discharges from the emergency department. This study further demonstrates the key role that emergency departments play in the coordination of inpatient as well as outpatient care.
According to the study, balanced by a 10 percent decrease in admissions from primary care physicians and clinical referrals, hospital admissions increased from 34.7 million to 36.1 million. The bulk of the increase was from so-called “non-elective” admissions from the emergency department–reflective of a rate that was 3.8 times the rate of population growth over the six year study period. The highest rate of admission was in those persons older than 65 years of age. Overall, self-pay patients were less likely to be admitted to the hospital than those patients with health insurance.
Because the average cost of an inpatientstay ($9,200) is roughly 10 times that of a comprehensive emergency visit ($922), the role emergency physicians play in determining whom to admit or discharge to the hospital is vital to reducing hospital expenditures.
Data obtained from the study indicates that 80 percent of patients who contacted their healthcare provider before arriving at the ED were instructed to proceed directly to the ED as opposed to visiting their healthcare provider. The findings of the study also revealed that healthcare providers are more likely to refer patients who have multiple comorbidities and who are ill to emergency departments for evaluation and further management.
The reality is that primary care physicians often rely on emergency departments to evaluate their patients after hours, facilitating and instituting detailed diagnostic workups, and admitting patients with significant medical illness. EDs are there for patients in acute need of care, often the only facility that remains open after hours, and provide a significant amount of acute care on holidays, weekends, and off hours.
One major issue that influences the decision of emergency physicians to admit patients is their access to follow-up care. Emergency physicians play an important role on a daily basis in deciding whom to admit to the hospital , and therefore are pivotal to hospital cost savings. This daily decision to admit or discharge a patient is balanced against the possibility that they might suffer injury or harm if they were to be discharged home.
The evaluation and management of common conditions including chest pain, pneumonia, COPD, abdominal pain and lacerations and soft tissue trauma are important conditions treated on a daily basis by emergency physicians. Working alongside hospitalists, emergency physicians play a key role in determining whether such patients end up being admitted or discharged home.
One important trend identified by the RAND report is an important requirement and need for timely and comprehensive follow-up care after a visit to the emergency department. Having the proper medications as well as a support system in place are instrumental in good patient care. The reality is that emergency physicians on a daily basis–with the assistance of social workers, case managers, primary care physicians and hospitalists–help to coordinate efficient delivery of care as well as follow up on a daily basis in hospitals in the US, in an attempt to fill the holes or gaps in coverage.
Efforts to remedy the coverage gaps should ultimately focus on increasing access to cost efficient care and strategies outside of the emergency department in order to reduce inappropriate use of emergency departments.
More recent strategies to shift care into other facilities, such as retail clinics or urgent care facilities has met with limited success, often due to lack of appropriate and available diagnostic testing, and inability to admit patients to the hospital. Most major insurances as well as Medicare are accepted, with occasional centers accepting medicaid or managed care medicaid plans. More importantly, these types of clinics will not see uninsured patients who cannot pay for their visits.
Newer, more specialized urgent care type facilities referred to as emergi-centers, staffed by emergency medicine physicians, have been gaining popularity in the past decade, with the ability to perform x-rays, reduce simple fractures, repair lacerations, along with performing limited medical workups. A number of these types of facilities will administer IV antibiotics, perform diagnostic ultrasound, as well as perform EKGs and point of care diagnostic blood tests. These facilities will accept most major insurance plans and Medicare, (some accept Medicaid/Medicaid managed care plans) but unfortunately do not serve as a safety net for the uninsured.
In summary, emergency physicians, working in hospital emergency departments represent 4 percent of US physicians, but provide 28 percent of all acute care treatment, 11 percent of all the outpatient treatment in the US, along with 50 percent of acute care management to Medicaid and CHIP beneficiaries and over 66 percent of all acute care treatment to the uninsured.
The RAND report advises policymakers, hospital administrators, as well as payers be aware of the important role emergency departments and emergency physicians play in coordinating care for all people in the US.
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