Affordable Care Act Puts the Squeeze on EDs

Studies find higher patient demand, lower consultant availability

Emergency departments (EDs) are experiencing higher demand from more patients but lower availability of consultant specialists since the implementation of the Patient Protection and Affordable Care Act (PPACA), according to two studies published in the Annals of Emergency Medicine.

One study focused on Illinois and the other on Massachusetts.

In the Illinois study, researchers examined ED use and hospitalizations through the ED after PPACA health insurance expansion in that state. Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients 18 to 64 years of age, the authors compared mean monthly ED visits before and after PPACA implementation by disposition from the ED and primary payer. The visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates.

The investigators found that the average monthly ED visit volume increased by 14,080 visits––a 5.7% increase after PPACA implementation. The monthly ED visit rate decreased by 8.7 visits per 1,000 uninsured residents; increased by 10.2 visits per 1,000 Medicaid beneficiaries; and increased by 1.3 visits per 1,000 privately insured residents. After adjusting for baseline trends and season, the changes remained statistically significant.

The authors concluded: “These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before [PP]ACA implementation.”

In the Massachusetts study, researchers conducted serial surveys of EDs to investigate trends in consultant availability. They surveyed ED directors in 2006 (n = 61), 2009 (n = 63), and 2015 (n = 63) about ED characteristics during the previous year, including specialty-specific consultant availability in person and continuous consultant availability.

The authors reported that, from 2005 to 2014, the median number of annual ED visits increased from 32,025 to 42,000; that the number of full-time attending physicians increased from 11 to 12; and that the number of full-time ED nurses increased from 27 to 42. In adjusted models, there were significantly reduced odds of consultant availability in 2014 compared with 2005 for general surgery (odds ratio [OR]: 0.05); neurology (OR: 0.39); obstetrics/gynecology (OR: 0.40); orthopedics (OR: 0.34); pediatrics (OR: 0.19); plastic surgery (OR: 0.10); and psychiatry (OR: 0.25).

According to HealthLeaders Media, the studies identified four ways in which the PPACA is squeezing EDs.

First, the Illinois study showed that the monthly visit volume is up. Lead author Scott Dresden, MD, MS, said: “A large post-[PP]ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in emergency department visits by uninsured patients. We still don’t know if these results represent longer-term changes in health services use or a temporary spike in emergency department use due to pent-up demand.”

Second, both studies documented major upticks in the annual visit volume. In Illinois, the volume grew from 2.9 million in 2011 to 3.2 million in 2015––an 8.1% increase. In Massachusetts, the median number of annual ED visits jumped from 32,025 to 42,000 in the decade between 2005 and 2015.

Third, the Massachusetts study showed that specialist access was down. The availability of general surgeons, for example, fell by 15%, while psychiatry availability declined by 23%.

Fourth, the Massachusetts study found that there aren’t enough rooms. The authors reported a 29% increase in EDs caring for patients in areas outside the ED, such as hallways—from 70% of EDs reporting this situation in 2005 to 89% in 2015.

Sources: HealthLeaders Media; September 9, 2016; AEM (Illinois); August 25, 2016; and AEM (Massachusetts); August 25, 2016.