Challenges Facing the Nation’s Emergency Care System: From Everyday Care to Disaster Preparedness
An interview with Nicole Lurie, MD, MSPH, the assistant secretary for preparedness and response at the U.S. Department of Health and Human Services, and an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program. She is the co-author of “The U.S. Emergency Care System: Meeting Everyday Acute Care Needs While Being Ready for Disasters,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. The interview is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
Human Capital Blog: You write that the nation’s emergency care system is in trouble. What are the challenges facing emergency departments (EDs)?
Nicole Lurie: We’ve understood for at least a decade that the emergency system is in trouble. We ask a lot of this system, and as a result we have EDs that are really crowded and with long wait times, boarding times and throughput times. It’s become a de facto access point for many people who lack access to primary care or insurance, which wasn’t what it was originally set up for. Now, EDs have evolved to be more than places to treat life and limb threats and serve as default diagnostic and therapeutic entry points. But many people who end up in an emergency department may be willing to be treated in a different kind of environment. It is really up to us to build a system that accommodates their needs and ensure our emergency care system can do its important work.
And remember: We changed the way we deliver care in the U.S. from a hospital-based focus to an outpatient focus over the last few decades, but we never really built the infrastructure for it. Outpatient providers have had their visits shortened and group practice environments have changed the relationship between patients and their primary care providers. We hear about the shortage of primary care providers and the crisis of crowding and boarding in emergency departments, but we don’t always connect the dots to understand how we got here. It is a good time to start to have this conversation as payment models are encouraging us to recognize that generating health for our patients is a team effort.
HCB: How do you see the emergency care system evolving, particularly with respect to disaster preparedness?
Lurie: Emergency preparedness rests on the back of strong day-to-day systems. Communities respond with the systems that are in place at the time of the disaster. So if those systems are having trouble performing day-to-day, they’ll really struggle when big emergencies or disasters strike. To be ready for emergencies, we need to be flexible and practiced, and many of the things we do every day contribute to that. And for the most part, the emergency care system is community-based and geographically based, just as the rest of the health care system is. But it’s evolving to something more regional, which is something we are seeing more and more in disaster preparedness, too.
One element to watch is how systems of care that are in competition with each other are able come together during a crisis when the whole region has to surge—and the lessons we can learn from this as they apply to our day-to-day work.
It always surprises me when people think about emergency care as a carve-out that is separate from reforms in the rest of the medical system. Emergency care is a giant piece of health care delivery in the United States with 130 million visits to the ED taking place each year. When we talk about emergency care reform, people say, “that’s really hard,” and the conversation stops! We need to sort out how to connect the outpatient care environment and the ED. And of course, we have to make sure that we have systems in place so that patients in need of medical care have options that meet their needs. We need delivery-system innovation. And I think we are learning a lot about how to do this by asking the medical community to innovate when payments are bundled. With this issue of Health Affairs, we hope to shine a light on emergency care as an essential part of the system that has to be thought about deliberately and carefully.
HCB: In your article, you discuss the problem of patients seeking non-emergency care at the ER, and note that some of that is because patients lack access to primary care or simply have difficulty getting in to see a provider when they’re sick. Presumably the Affordable Care Act will help with those problems in the long run, but how do you see it unfolding?
Lurie: I think your question is really about the impact of the ACA on the ability for patients to have options. The increased access and affordability of health insurance coverage and expanded Medicaid coverage available through the Affordable Care Act will enable millions to get plugged into primary care, and this could help reduce the number of people who seek care in an emergency room for lack of any other option.
In addition, we’re starting to see a lot of experimentation with care models that are patient-centered and community-centered. Even in the short term, those alternative models could offer some relief. These may come in the form of group visits, electronic visits, electronic home monitoring of patients or other models. The key here is to decide how we want care to be delivered and to then get the incentives lined up better. We note in the article, for example, that emergency medical services only get paid if they pick someone up and take them to an emergency department. A lot of people might do well with care on the scene, or if they were offered the choice of getting care somewhere else that’s more consistent with their needs. So it’d be prudent to look at the payment system to see if we can find ways to align the financial incentives so that they facilitate people getting the right care at the right time in the right place. And lastly, we need to ask the patients.
HCB: You discuss the need for developing a “community-centered emergency care system.” What would that look like, and what’s required to get there?
Lurie: A community-centered system is one in which people get the kind of care they need, when they want and need it, in settings that best meets their needs. It looks different from community to community, and there’s not a one-size-fits-all solution. It requires different parties—primary and emergency care providers in the community—sitting down together and figuring out and agreeing on guidelines for the types of situations that can be handled in an outpatient setting and [on] which are really best suited for an emergency department. And not just day-to-day, but also in disasters. Part of what’s exciting about this transformation is that it’s focused on meeting patients where they are and providing the best quality care.
It’s important to keep in mind that the emergency care system goes beyond a single ED; it’s a community-based system that’s there for emergencies, large and small. More and more, it is used for unscheduled acute care; even while people debate whether that’s a good idea. It’s a trauma care system that’s first rate, regionalized, has the centers of excellence that it needs to meet the community’s needs every day and in a large-scale emergency. No single institution can own all that, but the community as a whole can build a coordinated, dynamic system.
HCB: Tell us about the national Hospital Preparedness Program’s role in preparing local EDs and communities for disasters.
Lurie: The Hospital Preparedness Program is focused on ensuring that hospitals and other entities and providers can respond and recover when there are big emergencies—so, making sure they’re able to provide care in disasters, to surge if there’s a big mass casualty event [in the way that the health care system did in Boston after the marathon bombing, for example,] or to evacuate patients quickly if that’s what’s needed. It requires partnering with others, planning with those partners and practicing together. In planning and practicing, hospitals, EDs and other health care entities in the community learn better how to do what they do day to day, as they think about how they’re going to clear out the ED, how they’ll create beds by moving people to the next lowest level of safe and appropriate care, and so on.
One thing that’s special about the national Hospital Preparedness Program is that it doesn’t focus on just one hospital at a time, but on all of the health care entities in a community. So, for example, if one hospital is overwhelmed, another can pick up the slack. Or if a nursing home has to evacuate, it won’t suddenly crash a hospital because everyone went to one place. Or an ED can distribute patients to a range of institutions in an emergency event. So the program focuses on health care coalitions, organizations of all types, with all of the players in a community—hospitals, dialysis centers, medical homes, everyone.