The Changing Role of the Emergency Department
An interview with Renee Hsia, MD, a Robert Wood Johnson Foundation Physician Faculty Scholars program alumna and associate professor of emergency medicine at the University of California, San Francisco. She is the co-author of “Emergency Care: Then, Now and Next,” 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: Other than the obvious changes in technology, how are emergency departments (EDs) different today than they were 50 years ago?
Renee Hsia: We’ve had a dramatic transition since the 1950s, in terms of what emergency departments do, and the patient outcomes we expect. We mention in the article, for example, that years ago many emergency departments used funeral hearses to transport patients to the ED. Now transport is usually in vehicles with all sorts of life-saving equipment on board. That’s one reason the mortality rate is a lot lower now than it was then; death is much rarer in the emergency room today.
Another dramatic transition has been the rise of the specialist in emergency medicine. It used to be more common to have physicians trained in other specialties taking turns in the emergency room. You still see that in some rural areas, but it’s far less common. There’s been a gradual movement toward the understanding that we need people who are masters in the acute presentation of illness.
We’ve also seen the beginnings of a system transition, with a growing focus on regionalization. We have to account for the reality that not all community EDs and hospitals are equipped with the same technology as tertiary hospitals, such as a cardiac catheterization lab, for example. We need to be sure that we can get patients “the right care in the right place at the right time,” and that requires close coordination within the larger health care system.
HCB: You discuss the relationship between ED crowding and changes in primary care practice. Could you tell us about that?
Hsia: In discussions of overcrowding, you often see the media point fingers at uninsured patients or at undocumented immigrants. But when you look at the studies, first, you see that the majority of patients who go to the ED are privately insured. For many privately insured patients, even when they see their primary care physician, they’re often referred to the ED. That may be because primary care physicians are overbooked, or because there is the idea that the ED can obtain more rapid access to diagnostics than a clinic can. And it might be related to the fact that there’s no financial disincentive if their patient goes to the ED.
That being said, it is true that the group with the most rapid increase in ED visits has been Medicaid patients. That is also related to the fact that there are real challenges in obtaining services elsewhere. But we also know Medicaid patients tend to be sicker than their non-Medicaid counterparts, and therefore the health care they require is more intensive.
Overall, regardless of the insurance status, I think there’s also been a palpable culture change, where people expect to get seen right away, and want services now. And they know they can get seen at the ER if they wait long enough.
Finally, I think it’s important to remember that as people are living longer, they are also getting sicker as they get older. So when they do come to the ED, their visits are also more intense and time-consuming.
HCB: You also discuss the unintended consequences of the Emergency Medical Treatment and Active Labor Act (EMTALA), the 1980s law that makes clear that emergency departments have an obligation to “treat or transfer” patients with an emergency. Tell us about that.
Hsia: EMTALA is a very well intentioned piece of legislation, and it came about because some hospitals were dumping patients who were poor or uninsured. The purpose was to fix that, and certainly that’s something we’d all agree with—that we want people seen regardless of their financial circumstances. But some hospitals see that as an unfunded mandate. And if the hospital is in an area in which a lot of people don’t have insurance, it affects their bottom line in very real ways. For some hospitals, the ED is a revenue center, but for others it’s a cost center, and it just depends on the patient-payer mix. So EMTALA has contributed to the rise of specialty hospitals without emergency departments.
HCB: What are some of the trends that are going to shape the future of ED care?
Hsia: One is integration. Right now our system is fragmented, and it is not easy for hospitals to share information about patients. In fact, the patient confidentiality requirements of HIPAA (the Health Insurance Portability and Accountability Act) give them good reason not to. But patient care becomes compromised when information from one facility is not easily obtained from another facility. For example, patients might get more radiation from excess imaging if it’s too hard to get their images from another hospital, or patients get worked up for things that have been already diagnosed in the past. We need to encourage appropriate sharing of patient information so we can improve the patient experience and our ability to deliver efficient and high-quality care.
The financial piece is also very important. Currently the system does not provide significant financial incentives to integrate. We need to look at how we pay for care and how we incentivize systems so that everyone is accountable for overall cost and care. If a patient has an emergency, it’s not their primary care doctor’s fault, so it’s hard to say that we should financially penalize the primary care doctor if their patient has an ED visit. But at the same time, if the primary care doctor never has space to see patients with somewhat urgent problems, then those urgent problems do become emergencies. Similarly, patients shouldn’t have to wait in an ER to get an antibiotic that their primary care physician could prescribe, if only they could have gotten an appointment to see them. So we need to think carefully about how to create financial incentives to encourage high-quality and responsive care.
Team-based practice is another type of integration that’s increasingly important. Patients go from their primary care doctor to the ED, to inpatient care, and then out of the hospital, and sometimes doctors in each setting function as if they were in silos. We need to get better at making sure we really do function as a team across care settings so that patients aren’t left trying to connect the dots themselves.