Main Points

• Emergency visits are expected to increase, despite health care reform, as they have in Massachusetts, which adopted universal health insurance coverage in 2006.
• Health insurance coverage does not guarantee access to medical care.
• The health reform legislation includes the “prudent layperson” standard — which is being applied to all health care plans; ACEP advocated for this standard for nearly 20 years.
• ERs are a critical, life or death part of our health care system that need help now.
• The crisis in emergency care is everyone’s problem. Everyone is only one step away from a medical emergency.

Does ACEP support the health care reform bill that was enacted?

• ACEP advocated for provisions in the law to benefit emergency patients, but did not take a formal position on the health care reform law.
• The nation’s emergency physicians are dedicated to working to achieve the long-term benefits that true health care reform should bring. ACEP is asking Congress and the Obama Administration to recognize and fund the central role emergency medicine plays in the health care system.
• It is not clear how the health care reform legislation will affect emergency patients— it will become clearer as regulations are developed to implement the law.
• ACEP supports legislation that provides for the creation of a national bipartisan commission on access to emergency medical services to examine factors that affect the delivery of care in U.S. emergency departments. In addition, that legislation calls on the Centers for Medicare & Medicaid Services to develop standards, guidelines and measures to address emergency department boarding and ambulance diversion.

Why does the nation need to focus on emergency care?

• Emergency departments are closing their doors — where are people going to go?
  • Hundreds of ERs have closed in the past decade (CDC 2010). The number of emergency departments has decreased by 5 percent in 10 years, but the demand for care is up by 32 percent — up to 128 million visits in 2008, or 340,000 people every day. Emergency visit rates have increased at twice the rate of growth of the U.S. population from 1997 to 2007 (JAMA 2010).
• America earned a near-failing grade (D-) for its access to emergency care in the “2009 Report Card on the State of Emergency Medicine.” The nation’s emergency care resources are shrinking while the demand is growing, and the nation has too few emergency departments to meet the needs of a growing and aging population.
• Nearly two-thirds of emergency departments were classified as safety net hospitals in 2007 — defined as providing a “disproportionate share of services to Medicaid and uninsured patients” — which is nearly double the number classified as such in 1997. (JAMA 2010)
• A federal report says emergency patients who need care in 1 to 14 minutes are being seen in more than twice that time frame (37 minutes, Government Accountability Office, 2009).
• Emergency physicians provide a health care safety net for everyone, not just the uninsured.

Are there any provisions in the enacted legislation that focus on emergency care?

• The following provisions in the legislation will benefit emergency patients:
  • Inclusion of emergency services as essential to any benefits package.
  • Application of the prudent layperson standard (as part of the Patients’ Bill of Rights) to all health care plans, which means coverage must be based on a patient’s symptoms, not the final diagnosis.
  • Requirement for exchange health plans to provide emergency services without regard to prior authorization or emergency physician contractual relationships.
  • Authorization of the Secretary of Health and Human Services to pursue demonstration programs about medical liability reform alternatives such as health courts.
  • Reauthorization for five years of the Emergency Medical Services for Children program (under Department of Health and Human Services).
  • Direction of the Secretary of HHS to expand/accelerate emergency medicine research at organizations including the National Institutes of Health.
  • Requirement for HHS demonstration projects to reimburse private psychiatric hospitals that provide Emergency Medical Treatment and Active Labor services to Medicaid beneficiaries.

Shouldn’t the nation’s focus be on preventing people from using “expensive and inefficient” emergency departments?

• Most people who seek emergency care need to be there. Less than 8 percent of visits were classified as nonurgent in 2007 (CDC).
• Emergency care represents less than 3 percent of the nation’s $2.1 trillion in health care expenditures, yet ERs are highly efficient, caring for nearly 124 million patients each year. There are extra costs on an emergency bill, because ERs must be prepared to care for every kind of medical emergency and be available 24 hours a day.
  • Hundreds of emergency departments have closed because of uncompensated care. Less than 50 percent of emergency department charges are reimbursed, even though 83 percent of emergency patients have some form of health insurance.
  • Emergency departments have a federal mandate (EMTALA) to care for all patients, regardless of their ability to pay. However, the mandate is unfunded. The hospital’s actual costs for a nonurgent visit are similar to the costs of a family physician visit. Given the standby costs (staffing and equipment) to treat all patients 24/7, the extra (or marginal) costs of seeing an additional patient for an urgent or nonurgent problem are much less than what it would cost to open a private physician’s office after hours or build an urgent care center.
• Emergency care is timely and highly efficient because emergency physicians command the resources of the entire hospital, such as diagnostic equipment and consultants. When other office- or clinic-based physicians have seriously ill or injured patients, they send them to emergency departments. These doctors know that patients in an ER will receive rapid diagnostic evaluations and immediate lifesaving treatment.

Instead of giving more support to emergency patients, wouldn’t it be more effective to make sure everyone has a medical home?

• Emergency physicians support the basic tenets of the patient-centered medical home, although the concept is vague, and key specifics must be addressed to avoid unintended negative consequences.
  • The emergency department is, and will continue to be, every patient’s medical “home away from home.”
  • The medical home approach must be truly patient-centered. It must not function like the “gatekeeper” model of HMOs and access to emergency care must be protected.
  • Shifting financial and other resources to support the medical home concept could have tremendous adverse effects on emergency patients, especially if health care costs need to be cut. Furthermore, the medical home concept does not address the millions of people who are uninsured or underinsured.
  • It is not clear how the medical home concept will work, given the reality that most physicians’ offices are closed on nights and weekends, and many people are unable to get timely appointments during regular working hours because their physicians’ schedules are booked.
• The Massachusetts example proves that even universal coverage doesn’t guarantee universal access. After Massachusetts mandated that people have health insurance, visits to emergency departments increased 7 percent per year, and waits to see primary care physicians increased.

Health care costs are spiraling out of control, and some experts predict Medicare will go broke by 2016. How can your organization ask for more money to shore up emergency departments?

• How much is a human life worth? Huge amounts of uncompensated care have closed hundreds of emergency departments. In one decade (1997-2008), the number of emergency patient visits rose from 94.9 million to 123.7 million (a 37-percent increase) — or twice the rate of growth of the U.S. population.
• Hospital emergency departments have a federal unfunded mandate (EMTALA) to care for everyone, regardless of his or her ability to pay.
• Every practicing emergency physician provides on average $140,000 in uncompensated, EMTALA-related care each year.

For more information, visit www.acep.org