Increasingly, the hospital emergency department is becoming the admissions department.
The ED now accounts for more than one-half of hospital admissions, according to a recent Rand Corp. study. The ED accounted for only about one-third of admissions in the early 1990s, and the number has grown by more than 50 percent since then.
The study found that U.S. inpatient admissions grew less than 6 percent, which was slower than the U.S. population growth, between 2003 and 2009. However, nearly all of the growth in admissions was due to a 17 percent increase in admissions from the ED. That growth also more than offset a 10 percent decrease in admissions from physician offices and other outpatient settings.
Texas Health Resources’ ED admissions grew from 41 percent in 2005 to 56 percent in 2013, according to chief clinical officer and senior executive vice president Daniel Varga, MD. The migration of elective surgeries to outpatient clinics has been the major driver of ED admissions, and Varga expects the number of ED admissions to grow, but at a slower rate compared with the past decade.
“The lower-acuity cases are gone now,” he said. “We can foresee a time when a hospital will become one big ICU.”
Varga said ED admissions generally are lower-paying medical diagnoses, rather than surgical cases. He noted that single-specialty hospitals have a competitive advantage because most do not have an emergency department and are nearly all elective surgical admissions.
Varga made the distinction between the percentage of hospital admissions that come through the ED and the percentage of ED patients who are admitted. Busy EDs may create a greater percent of the facilities’ admissions, but most ED volume is not admittable, he said. Greater ED volumes can reflect lack of access to primary care and higher rates of uninsured residents.
Hospital administrators traditionally have considered the ED a “loss leader” because of the uncompensated care they are legally bound to supply. Hospital accounting practices often attribute revenues to the admitting department, rather than the department where the admission began.
EDs increasingly are being squeezed. ED visits grew by 26 percent between 1994 and 2004 while American hospitals shut down 198,000 beds. A 2007 Institute of Medicine report concluded the U.S. emergency care was overburdened, underfunded, and highly fragmented.
Health Affairs researchers estimate that the duration of ED visits will increase by 10 percent by 2050 because of an aging population, meaning that EDs will have to add resources by that amount to treat the same number of patients. They also found that admissions from the ED would grow 23 percent faster than the population during that time.
A separate study of California EDs from 2002 to 2009 found that the number of “high-intensity” visits doubled—characterized by use of advance imaging, consultations with specialists, and highly complex medical decision-making. Researchers speculated that the increased intensity was caused by sicker patients, greater availability of technology, and pressure to keep patients out of the hospital beds whenever possible.
Primary-care physicians increasingly are relying on EDs to evaluate complex patients with potentially serious problems. Many say they faced barriers in directly admitting non-elective patients to the hospital, and find the easiest course is to send patients to the ED for evaluation and possible admission. Their days are already packed with brief patient encounters and they cannot afford to take the time to see walk-in patients with urgent problems.
The upshot of all this is that ED physicians have become the gatekeepers for about half of U.S. hospital admissions, including two-thirds of those that are not elective.
Baylor Health Care System’s chief of emergency medicine Dighton Packard, MD, said its ED admissions have risen 10 percentage points to 53 percent in the past five years. People are arriving with more chronic conditions than a decade ago, he said, and regulatory requirements have increased the need for doing more tests on patients.
Packard said emergency medicine gets somewhat of a bad rap because of its expense. He contends ED providers efficiently test and diagnose in a short period of time. That efficiency might avoid a hospital stay or shorten the length of an admission.
“If you hurt your ankle playing basketball and it swells, you want to know if it’s broken,” he said. “There’s only one place you can find out in an hour, and be able to see an orthopedist in two hours.”
Steve Jacob is founding editor of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at [email protected]