What Massachusetts teaches us about emergency departments and reform

Derek DeLia and Joel Cantor of the Rutgers University Center for State Health Policy write on the possible impact of health reform on emergency department utilization.

A popular idea in the healthcare reform debate is that enrolling more Americans in health insurance coverage will decrease emergency department (ED) use and with that alleviate other health system ills like excessive costs and ED overcrowding. A recent paper by Sharon Long and Karen Stockley on Massachusetts’ recent healthcare reform adds to a growing list of studies that cast serious doubt on this idea.  Despite the state’s remarkable progress in covering the uninsured, its ED utilization patterns look very unremarkable. Although no pre-reform data are provided, the paper is consistent with prior studies summarized in our July 2009 Synthesis Report suggesting that expanded coverage alone will not decrease ED use.

Designers of the Massachusetts reform effort understood from the beginning that covering the uninsured would be only the first step. Accordingly, the state is now moving into the second phase of its reform effort with a greater focus on healthcare delivery and reimbursement. Now is a good time for Massachusetts (and the nation) to assess the role of the ED in a reformed system and how to define its “appropriate” use.

For decades, the ED has been the default provider of care for patients whose needs are not being met elsewhere. This is illustrated with the data presented by Long and Stockley. Although more than 90% of survey respondents have a usual source of care outside the ED, that care was often not available when the respondents were seeking it. This phenomenon (not unique to Massachusetts) is a reflection of the growing demand for unscheduled care in the U.S. and the inability of healthcare supply to keep pace.

In theory, some of this demand might be met by expanded primary care practice hours, “quick clinics”, or open access scheduling. In other cases, individuals with truly minor illnesses might be encouraged (through copayment structure or nurse-staffed phone services, for example) to exercise more patience and wait for a doctor’s appointment. But much of the demand for unscheduled care is derived from the rising number of individuals with acute flare-ups of chronic illnesses. These flare-ups often require rapid access to services such as advanced imaging, respiratory therapy, and acute pain management not commonly available in community-based practices.

Rather than viewing the ED as a place to be avoided, it would be better to view it as an integral part of the healthcare continuum to be used when needed. Practically speaking, this is already happening but mostly in an ad hoc and reactive manner. For example, in response to the demands placed upon them, many ED’s have begun to focus more systematically on the provision of primary care through fast track units and more intensive case management for repeat users with chronic illness. Moreover, as many health facilities become more specialized (e.g., cardiac surgery centers), ED’s continue to treat patients who do not fall neatly into a particular medical category.

Recent discussions of healthcare delivery reform have focused on how to operationalize concepts such as patient-centered medical homes and  accountable care organizations.   Yet little of that discussion has included a specific role for the ED in these new structures. This is an important omission, since limitations in the availability of community-based care and the growing demand for unscheduled care all but guarantee further increases in the use of the ED. As it enters the second phase of its healthcare reform efforts, Massachusetts is now in a prime position to lead the way on better defining and integrating the role of the ED in a reformed healthcare system.