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Special Report: Waiting for the Deluge

soRelle, Ruth MPH

doi: 10.1097/01.EEM.0000405484.63051.4e
Special Report
Patients fill the waiting room of the emergency department at John H. Stroger Hospital of Cook County in Chicago (formerly Cook County Hospital).

Patients fill the waiting room of the emergency department at John H. Stroger Hospital of Cook County in Chicago (formerly Cook County Hospital).

When the New York Times revealed in June that the Obama administration was recruiting “mystery shoppers” to make appointments with primary care physicians, the move raised hackles in the medical community, prompting physicians to accuse the government of spying on their practices. (

The administration quickly backed off the plan, but the controversy demonstrated how worried government officials are that a dearth of primary care physicians and medical homes may become even more acute when an estimated 30 million Americans gain access to care under the federal health reform law. The real story, however, is that without enough primary care physicians, those newly insured patients are going to seek care in the same place they went before they were insured. And emergency physicians are bracing themselves for the onslaught.

The fallout is yet to come, but two things are already clear, experts said. There will be short- and long-term effects of the Patient Care and Affordable Care Act, and the act is more insurance reform than reform of the health care system.

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As early as April, more than 80 percent of emergency physicians responding to a poll by the American College of Emergency Physicians said visits were increasing in their emergency departments. ( Eighty-nine percent of the 1,786 physicians who responded said they believe the number of visits will only grow as health reform is implemented incrementally, and more than half said they expected to see a significant increase in visits. Two-thirds of emergency visits occur after business hours, when doctors' offices are closed. (National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables. Centers for Disease Control and Prevention; Visits totaled nearly 124 million in 2008, an all-time high, according to figures from the federal Centers for Disease Control and Prevention. (No more current data are available.)

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More Patients

“We are facing interesting times,” said Sandra Schneider, MD, the president of the American College of Emergency Physicians. “We are going to have more patients than we ever had because of the aging of America and because more patients will be insured and able to get care for possibly the first time in their lives.”

Although primary care residencies saw a surge in enrollment this yearfor the first time in a decade (, shortages persist, as they do among general surgeons and emergency physicians. Health care should develop new models of care, such as patient-centered medical homes, said Dr. Schneider, also a professor and the chair emeritus of emergency medicine at the University of Rochester in New York. “There is a need to build a practice with nurse practitioners and physician assistants to augment the hours for seeing patients the physicians cannot see. That's a problem because it's also an expense to the practice, and there aren't that many midlevel practitioners, and some physicians aren't comfortable working with them. The emergency department will be called on to fill that gap.”

Emergency physicians need look no farther than Massachusetts to see how health care reform may play out nationally, said Vidor Friedman, MD, the president-elect of the Florida College of Emergency Physicians and the chair of the Federal Governmental Affairs Committee of ACEP. That northeastern state saw emergency department visits rise by more than nine percent when universal health insurance was enacted. (Ann Emerg Med; in press; “The reason is that the primary care physicians they say will take care of everyone don't exist,” he said.

But Dr. Friedman said EDs will see an initial spike in visits but not “a whole lot more because we are already seeing them.” The difference for emergency medicine, he said, is that the emergency department is the only access for patients who don't have insurance now or who have poor insurance. “It will be a small uptick but a one-time pop,” he predicted.

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Uncertainty about Insurance

What is more difficult to predict is what will happen with commercial insurance coverage, Dr. Friedman said. Employers are already purchasing insurance with higher deductibles, and patients are responding by not paying their deductibles, he said.

Problems abound: patients believe they have a right to health care, and federal law reinforces that notion, putting it into practice with the Emergency Medical Treatment and Active Labor Act, though without a mechanism to pay for it, he said. “The problem is that we have this public policy that's being supported by private industry,” he said, and the system can no longer support it.

But expanding Medicaid to those with incomes up to 133 percent of the poverty line, including adults without dependent children, will probably put more people in the emergency department, and that is not totally negative, said Dr. Friedman. “Medicaid is not good reimbursement, but it beats nothing. We lose less taking care of Medicaid patients than those who don't have insurance.” And if the insurance market does not totally degrade, “it may change the way we do collections,” he said. “This could be a good thing for emergency medicine.”

Dr. Friedman said he thinks employers will continue to offer health insurance, although it may be less than it once was. If insurance regulation can be enacted, he said he would be optimistic about health care reform. “One of the things we will push for is an insurer mandate for emergency care. If you are going to provide commercial insurance, it needs to be done in a way that emergency care is covered.”

Wesley Fields, MD, is chairman and founder of the Emergency Medicine Action Fund, which pools the efforts of the emergency medicine community to advocate for emergency medicine on health care reform. ( The large-scale economic factors of the situation are more compelling, he said. “The further out you look, the less the consequences have to do with the bill but more with irresistible macroeconomics. Everyone knows the public trust funds for Medicare are going to go bust and that Medicaid is chronically underfunded at the state and local levels. Current rates of increase in the cost of private insurance are not sustainable. Most people's access to health insurance through their employers is in jeopardy.”

In the end, Dr. Fields said, none of these things is political, but they have become that — and emotional and personal. The big picture is that the pie is not getting bigger in terms of revenue and resources, and the population is aging. It is not sustainable for everyone to get everything.”

Dr. Fields said the rest of the health care system should ask more fundamental questions about how to provide the right care in the right place. “Part of what disappoints me about the political aspect of this is that somehow a trip to the emergency departments is a failure for the system,” he said. “If we are looking for uniformity, access, and quality, we in the emergency department have been providing all of that since 1986. The reason people keep showing up is that it is the only place in the system where you get what is medically necessary, not only when it's authorized or approved.”

Patients on stretchers line the wall of the trauma unit in the emergency department at Grady Hospital in Atlanta.

Patients on stretchers line the wall of the trauma unit in the emergency department at Grady Hospital in Atlanta.

While he said he hopes reform means patients will have access to continuing care and needed medications, he also wants emergency departments to maintain their role as the final safety net. “We are not the problem,” Dr. Fields said, noting that emergency care accounts for only about two to three percent of the nation's health care bill. That's why he created the Emergency Medicine Action Fund, to stop EDs from being blamed for the nation's burgeoning medical bill. “Look at the bigger picture,” he said. “It's not about uninsured or inappropriate patients but about people who have entitlements and consume resources of marginal benefit.”

Dr. Fields said one thing policymakers have gotten right is that the United States spends twice as much money as the rest of the world for outcomes that do not measure up in quality, adding that he hopes they understand that EDs have been the interface between the community and the hospital for more than 50 years.

“There are 40,000 highly qualified people who are national experts on which conditions are stable enough for referral and which have to go to the hospital. What emergency physicians do night and day is integrate patients with the rest of the system and create priority around their medical needs,” Dr. Fields said.

Emergency medicine, he said, will be part of the solution once the specialty repositions itself in the minds of policymakers. “We are the integrators of care, the traffic cops, and the triage officers between the medical home and the technology of the hospitals. I'm comfortable being patient-centered because that's what I've been doing one patient at a time, 80,000 times over the last 30 years.”

Brent Asplin, MD, a long-time emergency physician, has put himself in the forefront of health reform in his new role as president of Fairview Medical Group, a Minneapolis-based multispecialty group that staff 40 clinics. Like others, he pointed out that the current reform effort is directed at making insurance available. “If we get to a value-driven system, we will need both health insurance coverage and a reformed delivery system,” he said.

Gaps lie between health insurance expansion in the Patient Care and Affordable Care Act and the vision of a reformed delivery system, Dr. Asplin said, and “emergency departments across America are going to stand in that gap.” Like Dr. Fields, he said he sees the emergency department as an interface between the hospital and community systems of care. “Emergency physicians make the most expensive routine decisions in health care: Are you coming into the hospital? They will continue to make that decision regardless of how health care evolves over time.”

As patients continue to come to the emergency department, possibly in greater numbers in the first years of health care reform, Dr. Asplin said it is crucial that emergency physicians not become defensive as primary care systems develop to take up the slack. “That's the least of our worries,” he said. “If there is a highly efficient primary care system willing to take our patients away, we should stand up and cheer, as long as it is a safe and reliable alternative. That is what the system needs. We are going to have plenty of patients, even in communities with good access to primary care.”

In a perspective called “The ER, 50 Years On” in the New England Journal of Medicine, Arthur Kellermann, MD, MPH, the director of Rand Health, and Ricardo Martinez, MD, an assistant professor of emergency medicine at the Emory School of Medicine in Atlanta, pointed out that “emergency physicians provide more acute care to Medicaid patients, beneficiaries of the Children's Health Insurance Program, and the uninsured than the rest of U.S. doctors combined.” (2011;364[24]:2278;

Or as others eloquently put it more than a decade ago: The ED is more than a hospital department; it's “a room with a view” of our health care system. (Ann Emerg Med 2001;37[5]:500; J Emerg Nurs 1992;18[5]:368.) How that view evolves is the responsibility of the physicians themselves in a changing health care landscape.

“Modern ERs offer two competing views of the future. One, driven by deteriorating access to care, is a future where primary care is unavailable, specialty care is unaffordable, and no one answers the phone after 4 p.m.,” Drs. Kellermann and Martinez wrote. “It's a future where a trip to the ER is a perilous journey filled with lengthy waits, harried staff, non-existent privacy, and the prospect that any patient may fall victim to medical error. The alternate view is much brighter. It's a future where health care is centered on the needs of patients, not the convenience of providers. Health information flows readily and securely from a patient's home to his or her doctor's office, the ER, or the hospital — whenever and wherever it's needed. Thanks to teamwork and a powerful commitment to safety, care transitions are seamless and risk-free. As a result, patients consistently get the right care at the right time in the right place.

Or as management consultant Peter Drucker once observed, “The best way to predict the future is to create it.” And that's what Drs. Kellermann and Martinez ask, “What future do we want for our patients? The choice is up to us.”

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Understanding Health Care Reform

For an interactive timeline for the changes mandated by the Patient Care and Affordable Care Act, visit

© 2011 Lippincott Williams & Wilkins, Inc.