Dream On By Neal E. Flomenbaum, MD, Editor-in-Chief

Almost two years have passed since the Institute of Medicine (IOM) issued its report entitled Hospital-Based Emergency Care—At the Breaking Point. In it, the IOM noted that the ED has not only become the place that acutely ill or injured Americans turn to first, but also one that has been given an increasing number of additional responsibilities caring for both the uninsured and insured patients whose physicians are unavailable—particularly at night and on weekends—or who need tests or procedures that can’t easily be performed in their doctors’ offices. Alarm was expressed over the serious problem of overcrowding, exacerbated by the boarding of admitted patients in ED hallway beds for 48 hours or more while they waited for inpatient beds. 

The report concluded that the emergency care system had become a “victim of its own success” and, warning of its imminent collapse, the IOM recommended corrective measures that included adapting successful engineering and business practices, new and stronger JCAHO requirements, and an infusion of  federal money to offset the ED’s “money-losing” status.

How have we done since the IOM issued its report? Consider the following:

• In June 2007, the CDC released its 2005 Emergency Department Summary, noting a 31% increase in visits per ED since 1995, including a total of a half-million visits by homeless people and almost 2.5 million visits by people who had been discharged from the hospital within the previous seven days. The average patient spent almost an hour waiting to see a physician and 3.3 hours for the entire visit.
• On July 10, 2007, President Bush told a Cleveland audience: “People have access to health care in America. After all, you just go to an emergency room.”
• On January 15, 2008, Andrew Wilper and colleagues reported in Health Affairs that between 1997 and 2004, the waiting times to see an emergency physician increased 36% for all patients, 40% for patients triaged as needing immediate attention, and 150% for those with acute MIs. At the same time, total ED visits increased by 26%, while the number of EDs decreased by 12%.

With few or none of its recommendations acted on, this hardly seems to be what the IOM had in mind.

So do we give up? Or do we continue to seek short- and long-term solutions? Commenting on his Health Affairs report in Harvard Science, Wilper suggests that while hospitals lose money on ED patients, elective patients needing procedures are more lucrative. The IOM, Wilper, and many others see a direct connection between the nationwide crisis in emergency care and the failure to provide adequate financing for that care.

But merely throwing money at EDs will not solve the problem. The way to restore profitability to EDs, while providing incentives for inpatient services to admit patients faster, is to earmark third-party reimbursements to locations in the hospital where patients receive care during each stage of an admission. In doing so, EDs will be more fairly reimbursed for patient visits. Hospitals will then have financial incentives to increase ED capacity, and inpatient services will undoubtedly find ways to bring patients to those services sooner to capture a larger proportion of their admission stay—and revenue.

With increased capacity and decreased lengths of stay for admitted patients, the “treat and release” patients—still the majority of ED patients—will also be treated more efficiently. This will result in further decreases in lengths of stay and decreases in ambulance diversions. And then…

…and then I woke up.

Emerg Med 40(3):8, 2008