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Congressional Research Service (CRS)

 

Hospital-Based Emergency Departments: Background and Policy Considerations

Elayne J. Heisler, Specialist in Health Services

Nancy Leigh Tyler, Research Associate

December 8, 2014

http://www.fas.org/sgp/crs/misc/R43812.pdf

[full-text,m 44 pages]

 

Summary

Hospital-based Emergency Departments (EDs) are required to stabilize patients with emergent

conditions regardless of the patients’ ability to pay as a requirement of the Emergency Medical

Treatment and Active Labor Act (EMTALA). Given this requirement, EDs play an important part

in the health care safety net by serving the uninsured, the underserved, and those enrolled in

Medicaid. Open 24 hours a day, EDs provide emergency care, urgent care, primary care, and

behavioral health care services in communities where these services are unavailable or

unavailable after hours. EDs also play a key role during emergencies, such as natural disasters.

 

Some EDs are challenged to provide effective care. For example, EDs provide a disproportionate

amount of health care to the U.S. population, in general, and to the safety net population, in

particular. Specifically, while 4% of all U.S. physicians are ED physicians, they are the treating

physicians in 28% of all acute care visits. Some EDs face financial challenges. ED services are

costly both to payers, because services provided in an ED are more costly than those provided in

community-based settings, and to hospitals, because operating an ED has high fixed costs and

because if patients enter with an emergent condition, hospitals are required by EMTALA to

stabilize the patient regardless of the patient’s ability to pay.

 

As providers of uncompensated safety net care, some EDs are crowded, in part because hospitals

lack staff or inpatient beds to transfer patients from the ED, and in part because of the large

number of patients who seek care in the ED because care is unavailable or inaccessible in the

community. Crowded conditions have resulted in some patients experiencing long wait times,

which, at times, delays access to care and results in worse health outcomes. In addition, hospitals,

particularly those in urban areas, are regularly diverting ambulances because they are too

crowded to accept new patients.

 

This report describes EDs and the role they play in the health care delivery system. It also

discusses the federal role and interest in supporting emergency care. The federal government is

the largest payer for overall health care, through the Medicare and Medicaid programs. Also, the

federal government has made investments in emergency preparedness, programs and efforts that

support the health care safety net, and health care access in general. Given these investments,

Congress may be interested in EDs because a well-functioning ED system is necessary to provide

surge capacity in an emergency. The function of the ED system, in turn, reflects its surrounding

community’s access to health care services; therefore, understanding the use of EDs, evaluating

whether such use is appropriate, and examining strategies employed to reduce inappropriate use

may all be of policy interest.

 

This report discusses three commonly identified and interrelated challenges that EDs face: (1)

crowding in EDs, (2) providing repeat care to a subset of patients who are frequent users, and (3)

providing care to a large population who have behavioral health conditions when an ED lacks the

appropriate resources to provide such treatment. Finally, this report concludes with some policy

options that Congress might consider to improve ED functioning and reduce payer costs. This

report focuses on EDs that are available to the general population; as such, it does not include

EDs operated by the Departments of Defense or Veterans Affairs or those operated by the Indian

Health Service.

 

Contents

Introduction ...................................................................................................................................... 1

EDs and Health Care Delivery ......................................................................................................... 4

EDs Fill Gaps in Available Care ................................................................................................ 5

EDs Provide Care to Safety Net Populations ...................................................................... 5

EDs Provide Behavioral Health Care .................................................................................. 6

EDs May Not Be Used Appropriately ....................................................................................... 7

EDs Provide Primary Care ........................................................................................................ 8

EDs Are a Gateway for Inpatient Admissions ........................................................................... 9

The ACA May Affect ED Use ................................................................................................. 10

New Types of Health Care Facilities May Change the EDs’ Role .......................................... 11

Federal Regulation and Support of ED Services ........................................................................... 12

Emergency Medical Treatment and Active Labor Act (EMTALA) ......................................... 13

Tax-Exempt Hospitals and Charity Care ................................................................................. 14

Coverage of Emergency Care and Federal Insurance Programs ............................................. 15

Federal Support for Uncompensated Care ............................................................................... 15

Emergency Preparedness ......................................................................................................... 16

Trauma Care ............................................................................................................................ 17

Healthcare Safety Net .............................................................................................................. 17

Behavioral Health Support ...................................................................................................... 18

Care Coordination ................................................................................................................... 18

Research .................................................................................................................................. 19

Selected Issues Affecting EDs ....................................................................................................... 19

Crowding ................................................................................................................................. 19

Causes of Crowding .......................................................................................................... 20

The Effects of Crowding ................................................................................................... 24

Strategies That May Reduce Crowding ............................................................................. 27

Frequent ED Users .................................................................................................................. 28

Strategies That Target Frequent Users ............................................................................... 30

Behavioral Health Care in EDs ............................................................................................... 32

Causes of Increased Behavioral Health Treatment in EDs ................................................ 32

Effects of Treating Behavioral Health Care in an ED ....................................................... 33

Strategies to Reduce ED Use for Behavioral Health Conditions ...................................... 34

Policy Levers Available to Congress ............................................................................................. 34

Oversight ................................................................................................................................. 35

Changes to Federal Program Requirements ............................................................................ 35

Directed Spending ................................................................................................................... 36

Spending and Reimbursement Through Mandatory Programs ......................................... 36

Spending Through Discretionary Programs ...................................................................... 37

Changes to Statutory Mandates ............................................................................................... 38

Watchful Waiting ..................................................................................................................... 39

Concluding Observations ............................................................................................................... 40

 

Figures

Figure 1. Input-Throughput-Output Model of Emergency Care .................................................... 22

 

Tables

Table 1. Emergency Department Visits ............................................................................................ 2

Table 2. Three Types of Frequent ED Users .................................................................................. 29

 

Contacts

Author Contact Information........................................................................................................... 40

 

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