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Emergency Care System on Verge of Collapse? : An Institute of Medicine panel thinks so, and wants Congress to create a lead agency to resuscitate it.


 

WASHINGTON — Strained by rising demand and insufficient resources, the nation's emergency care is in a precarious state, an Institute of Medicine expert panel has concluded, and Congress must act to shore up the system.

Emergency departments are closing, the pool of available on-call specialists is drying up, and access to timely care in an appropriate setting is on the decline, warned Dr. A. Brent Eastman, chief medical officer of Scripps Health in San Diego, at the public release of the report compiled by the IOM's Committee on the Future of Emergency Care in the U.S. Health System.

The emergency care system's troubles are an especially frightening reality considering that it has traditionally provided the care of last resort, catching those unfortunate patients who have slipped through the gaps of the health care safety net, Dr. Eastman added. There is no longer any guarantee that it will be there when those patients need it, he cautioned at the meeting on emergency care sponsored by the Institute of Medicine.

The IOM panel recommended that Congress establish a single lead agency to oversee and manage emergency care, pulling together resources that are now currently overseen by an array of departments within various agencies, including the Department of Health and Human Services, the Department of Homeland Security, and the Department of Transportation.

As the committee envisioned it, that new lead agency would have planning and budgetary authority over the majority of emergency care activities at the federal level. Such an agency could raise the visibility of emergency medicine and emphasize the need to fund it. The agency would also coordinate how those federal dollars are spent.

Among other recommendations, the panel urged Congress to fund a demonstration program, to the tune of $88 million a year for 5 years, to assess strategies to coordinate and streamline the emergency care system. Federal agencies also need to support the development of national standards for measuring performance, the IOM said.

The report documents a host of issues besetting the emergency care system, including crowding, boarding, and diversions.

“The signs of distress are unmistakable,” said Dr. Arthur Kellermann, an IOM committee member and professor of emergency medicine at Emory University in Atlanta.

Over the past decade, visits to the emergency department—now up to about 114 million a year—have risen twice as fast as population growth. During the same period, the number of EDs shrank by 425, and the number of inpatient hospital beds fell by nearly 200,000.

“Do the math—with more people needing care and few resources available to provide that care, crowding in the ED was inevitable,” Dr. Kellermann said.

And with fewer hospital beds available, more severely ill and injured patients are boarded in the emergency department's exam rooms or even hallways until an inpatient bed can be made available.

“Some of them wait for hours, others wait for days. Meanwhile, other emergency patients are arriving every hour,” he said.

Often, EDs have no alternative but to divert inbound ambulances to other facilities. “When I started in my career, this was considered a rare and disturbing event,” Dr. Kellermann said. “It now happens more than half a million times a year in the United States.”

Demand Outpaces Resources

Emergency department responsibilities have grown over the years, with many now being expected to provide primary care to the uninsured, diagnostic services at night or on the weekend, and behavioral health care to the community.

Meanwhile, revenue has not kept pace. Medicare and Medicaid pay below cost for many emergency services, and uncompensated care has risen.

The emergency department is considered such an important public good that it is the only medical service that all Americans have a legal right to access. But hospitals are expected to finance that care through the free market system, Carmela Coyle, senior vice president for policy at the American Hospital Association, said during a briefing the day before release of the IOM report.

And because of low, and sometimes no, reimbursement, hospitals are finding it increasingly difficult to convince specialists to agree to be on call to the emergency department.

Liability, especially in a setting where many uninsured patients are in poor health, is also a major concern for specialists, according to an AHA survey.

“It's tough to get called at two or three o'clock in the morning to come in for a case where you know you might not get paid and you might get sued,” Ms. Coyle said.

Some hospitals have begun to pay specialists a retainer to be on-call, but that is just another financial burden making emergency departments a money-losing proposition, she said.

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