ED Crunch Not Necessarily Medicaid, Uninsured Issue

A study released yesterday by UC San Francisco showed a 23% increase in the number of people visiting U.S. hospital emergency departments over the past decade. Those numbers match a CDC report that came out a week ago.

The commonly held view is that rising numbers of uninsured patients and declining Medicaid reimbursements account for the spike in emergency room visits.

Not so fast, Angela Gardner of the American College of Emergency Physicians said.

“It is a commonly held myth that the uninsured are increasing, and that’s the reason all emergency departments are increasing — and the data don’t show that,” Gardner said.

Instead, she said, her organization has noted an increase in emergency room usage across the spectrum of insured, uninsured and underinsured.

“It is fairly safe to say,” she said, “that emergency room visits since 1990 have gone nowhere but up.” The causes are more complicated than blaming the increase on uninsured patients, she said.

The population is getting older and therefore sicker. That’s especially true in California, where 20% of the population is age 60 or older — a percentage expected to rise dramatically in the next decade as baby boomers swell the ranks of elder Californians.

She said it’s also a myth that emergency departments are full of patients wanting minor or preventive health care. “According to the CDC data, only 7.9% are in the ER for non-urgent care,” she said. “That’s down from 12% in 2006. I guess what that means is, 92% of those patients do need to be seen,” Gardner concluded.

The continued rise in demand for emergency services is made more dramatic by the decline in EDs across the nation. The UCSF study estimated that the number of emergency departments declined by 5% in the past decade.

But that statistic may be misleading, according to Glenn Melnick, director of the Center for Health Financing, Policy and Management at the University of Southern California. He is author of a study on California’s emergency department capacity. (The study was commissioned by the California HealthCare Foundation, which publishes California Healthline.)

Melnick said many of the nation’s emergency departments have closed because many small hospitals have closed. But the emergency departments’ capacity in an area could actually increase, even with a decrease in the number of EDs, he said.

For instance, in California, the number of emergency departments declined in the past decade. But according to Melnick’s report, “Despite the decline in the number of EDs, the number of ED beds increased consistently throughout the period. There were 4,994 ED beds statewide in 1996, and 6,310 in 2007, a 26% increase. During this time the population in California increased 15%,” Melnick said.

The reason for the increase in capacity? Melnick said it’s simple — just follow the money.

“Emergency departments are like a cash cow for a hospital,” he said. “That’s where money is made.”

According to Anne Drumm of the California Office of Statewide Health Planning & Development, the number of emergency departments in California has held steady over the past five years. In 2005, California had 330 hospitals licensed for emergency services. In 2009 that number was 331.

The American College of Emergency Physicians posts a state-by-state report card on its website. California gets good marks for public health and injury prevention — but overall, the state rates a D+ overall in emergency care services (compared to the overall national C- grade). California earned an F in access to emergency services.

“It is a little scary,” Gardner said of the rise in demand for emergency departments. “The ER is not just a safety net for Medicaid patients, it’s a safety net for everyone. And if it’s 20% more crowded than it should be, that affects your care.”



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