Health reform ruling won't solve emergency room overcrowding

Karen Cheung

 Karen M. Cheung

Even though many patients and providers breathed a sigh of relief last week when the Supreme Court ruled that the Affordable Care Act is constitutional, they're still keeping their fingers crossed when it comes to overuse and overcrowding in the emergency room.

According to the American College of Emergency Physicians, ER visits will continue to rise, regardless of the ruling.

"[W]hile there are provisions in the law to benefit emergency patients, it is clear that emergency visits will increase, as we have already seen nationwide," ACEP President David Seaberg said in a statement last Thursday, citing both physician shortages and drug shortages.

With half of health leaders reporting that their emergency departments are overcrowded as is and overcrowding growing twice as fast as ER visits, it's grim news for hospitals, still struggling with the ever-growing ER problem.

"Increasing the number of patients on Medicaid without an equivalent increase in the number of physicians willing to take that insurance will surely increase the  flood of patients into our nation's ERs," Seaberg said. "Coverage does not equal access, and critical problems facing emergency patients are not going away."

With overcrowding issues, hospitals face growing concerns about delayed care for truly emergent cases. For example, when ambulances are forced to reroute away from overcrowded emergency departments, heart attack patients see a 3 percent higher risk of death, according to a study published last month in the Journal of the American Medical Association (JAMA). ED overcrowding and ambulance diversion not only affects the diverted patients but also patients receiving care while the ED is on diversion status and nearby hospitals receiving the diverted patients.

EDs all have to deal with the problem of unemployed patients--hovering at about 8 percent nationally--according to Jonathan H. Burroughs, a certified physician executive and fellow of the American College of Physician Executives, president and CEO of The Burroughs Healthcare Consulting Network and contributing blogger for Hospital Impact.

Theoretically, the ACA will provide coverage for 32 million additional people--at least that's the number most frequently attached to healthcare reform. However, with states' option to forgo Medicaid expansion to individuals and families who meet the 133 percent criteria of the federal poverty guidelines, the number of newly insured persons could be fewer than anticipated. On top of that, many small business employers and individuals still will say no thanks and simply pay the tax because it costs less, according to Burroughs.

"This will exacerbate the resources of EDs to maintain adequate staffing, and the acuity will continue to rise as individuals postpone medical intervention for minor health issues," Burroughs said in an email to FierceHealthcare.

Compounded with reduced funding, hospitals are stuck between a rock and a hard place.

"Funding is going down everywhere as managers are realizing that their new mandate is to do more with less and everyone is seeking ways to reduce operating costs by at least 30% in all clinical settings," Burroughs said.

With EMTALA (Emergency Medical Treatment and Active Labor Act) regulations, providers still must conduct timely evaluation of potential emergency medical conditions (EMC), requiring "physicians, nurses and managers to work together to redesign their clinical and functional processes to make them safer and more efficient," Burroughs said.

How can hospitals ease overcrowding and improve flow in emergency departments?

Hospital leaders can continue to take costs-savings measures, including moving stable and non-EMC patients to less expensive settings such as a walk-in center or observation area, staffed by nurses, Burroughs noted. In addition, EDs are eliminating the traditional triage by a registered nurse and instead having an advanced practice nurse conduct an emergency medical screening and more rapid transfers out of the ED for stable patients who do not require physician exams.

 "The PPACA is not going to fix healthcare. This will require more radical change," Burroughs said about better disease management and eliminating fee-for-service. "[It's about] enabling real partnership between the patients and his or her practitioners by creating real financial incentives for patients who make wise healthcare decisions," he said.

How is your hospital handling the reform news? Is your ED anticipating an influx of patients and how has it adjusted its processes? We'd love to hear how your institution is coping. - Karen (@FierceHealth)