Editor’s Note: Read Dr. Cedric Dark’s commentary on this EMRA + PolicyRx Health Policy Journal Club article.

How much does the emergency department contribute to health care delivery in the United States? Do our policies reflect the emergency department’s current role?

A recent study assessed the contribution of emergency departments to the health care received in the United States compared to that of other outpatient and inpatient services from 1996 to 2010.¹ Using data from two nationally representative samples, the authors found that emergency departments accounted for 47.7 percent of non-federal hospital–associated medical care, with that percentage steadily increasing over the study period.

Populations found to account for the increase in emergency department utilization included Medicare and Medicaid recipients, African Americans, women, and residents of the South and the West. These findings point to the emergency department’s unique role in providing care to the most socioeconomically vulnerable Americans, filling the gaps in care access. In a time of turbulent health care reform, when accessibility and affordability are often in flux, emergency care continues to have an essential role in our country’s health care system.

Despite the emergency department’s important role, current models of health care delivery, including patient-centered medical homes and accountable care organizations, often fail to consider the full extent of emergency medicine’s contributions. The authors discuss the emergency department’s controversial role in treatment of nonemergency cases. Nonemergent care is often cost-ineffective and a poor use of resources. However, given that many populations who seek the emergency department for nonemergent conditions do so because of limited options for access, denying these patients treatment would be uncompassionate.² The emergency department must play a role in improving how vulnerable populations receive care. This approach should be better integrated with outpatient systems and resources.

Since Medicaid expansion under the Affordable Care Act, evidence suggests that overall utilization of the emergency department has actually increased, while low-acuity visits are on the decline.³ Assuming these trends continue, future health care reform must remain cognizant of the emergency department’s large contribution to the overall system. Current efforts to discourage the use of the emergency department for nonemergent care through coverage denial is a dangerous exercise that only exacerbates barriers to patient access.⁴ Policies should not seek to curb emergency department usage but instead include the emergency department as a coordinated component of health care delivery models. 

Dr. Bermudez is an emergency medicine resident at Vanderbilt University Medical Center in Nashville, Tennessee.

References

1. Marcozzi D, Carr B, Liferidge A, et al. Trends in the contribution of emergency departments to the provision of hospital-associated health care in the USA. Int J Health Serv. 2018;48(2):267-288.
2. Trueger S. On “unnecessary” ED visits: background reading. MDaware.com website. Accessed March 19, 2019.
3. Sontaag RJ. ER visits rise after Medicaid expansion. Policy Prescriptions website. Accessed March 19, 2019.
4. Wooster L. ACEP stands up for prudent layperson. ACEP Now. 2018;37(3):16.