The Emergency Department: The Nexus of Healthcare

Experts predict between 130 and 140 million patients will be seen in our nation's emergency departments in 2013. For the moment putting aside the fact virtually every ED has patients frequent them for care and services, the number alone represents approximately 44 percent of the population, a staggering number of patients. Questions are constantly being raised over what percentage of these patients are emergent, and/or how many of the patients do not really need the ED. The more technical version of this issue arises when examining the acuities of ED patients. The evidence discussed extensively by Pitts,1 et al.  shows an ever increasing acuity of patients. Raven, et al.2 and Adams 3 recently focused the issue when they clearly reinforced the nature of emergency care as truly being based on the "presenting symptoms" of the ED patient and not the final diagnosis. It is critical to reinforce the former point as truly being the domain of emergency medicine where virtually the entire continuum of care across the whole spectrum of healthcare is presented every day.   

140 million ED patients will be treated at a cost of between five percent and 10 percent of the total U.S. healthcare expenditures, according to the results reported very recently by Lee et  al. 4 The critical point is the ED is at the very nexus of the entire healthcare system. Every day in our EDs, emergency physicians are presented with the entire spectrum of illness, injury and human frailty. By federal mandate through EMTALA, every patient must be seen and evaluated, unlike any other site of care in the system. ED physicians cannot turn anyone away, a completely unique situation. Today many hospitals are designing programs to specifically address the "non-emergent" patient. Medicaid expansion means more patients will be insured, but this may also likely spike ED volumes, at least until the U.S. primary care network substantially increases and expands, which many predict will take decades.  

So it is time to recognize emergency physicians for the critical role they play in today's evolving new healthcare world. Reimbursement structures will likely change, and it is critical that emergency medicine have a central place in this new structure. Although much of today's discourse, discussion and rhetoric focuses on the non-emergent patient, the preservation of the prudent layperson definition of an emergency will continue being the hallmark for the legitimate justification of emergency care. There are two critical issues here. First, the prudent layperson definition of an emergency as defined in the Balance Budget Act of 1997 is as follows:

"Emergency services are those services which are for a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, possessing an average knowledge of medicine and health could reasonably expect that the absence of immediate attention would result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part."

The second and complimentary part of this issue is directly related to today's plans for Medicaid expansion. In particular, the now centrally important letter of Sally Richardson5, the then director, Center for Medicaid and State Operations of the Division of Health and Human Services, specifically bound Medicaid Managed Care organizations to this definition. The key phrase in the letter is as follows:

"While this standard encompasses clinical emergencies, it also clearly requires Managed Care Organizations to base coverage decisions for emergency services on the severity of the symptoms at the time of presentation and to cover examinations where the presenting symptoms are of sufficient severity to constitute an emergency medical condition in the judgment of a prudent layperson."

This definition remains in effect today and is critically important as a central component of all emergency physicians' insurance contracts.    

Once the patient is in the ED, the emergency physician is our healthcare system's best and most qualified professional to assess, diagnosis and disposition the patients who present there. There are a minimum of three critical revenue generating decisions made daily by emergency physicians. The first and arguably the most critical, revenue generating decision impacting all hospitals today is made when the ED physician decides to admit a patient. Emergency physicians' decisions to admit their patients contribute substantially to every hospital's overall revenue. In fact the Rand study6 just released substantiated in 2009 inpatient admissions from the ED accounted for roughly half of all inpatient admissions in the United States. Conversely, the counter decision of not to admit, similarly impacts the entire downstream outpatient system of care. Until the primary care network can support and sustain the full complement of ED discharged patients, these patients truly present one of the most challenging subsets of patients as ED physicians struggle knowing at least some of their patients literally have nowhere else to obtain care other than in the ED. It is this scenario of access to care that results in the ED being characterized as the healthcare "safety-net." It is likely more aptly named healthcare's "nexus of care" at least for the foreseeable future.

Then there is the ominous situation today of hospitals being financially penalized for readmissions. Once again the ED physician is at the epicenter of this solution, particularly by providing observation care in the ED, for patients warranting it. In this instance the ED physician observing the patient potentially saves the hospital from a readmission penalty, or a short-stay denied admission, while at the same time saving healthcare insurer dollars by preventing the full inpatient admission.

It is for these reasons emergency physicians must be "at the table" especially as the structure and function of our health care system evolves moving toward more accountable care organizations and similar models of care. There is great fluctuation and change within hospitals and systems today and as stated above the primary care network is not yet ready to absorb patients who arguably may not need emergency care. The stable and critical nexus of care however continues to be emergency physicians 24/7/365.  


1 Pitts, Stephen R., MD, “Higher Complexity ED Billing Codes, Sicker Patients, More Intensive Practice, of Improper payments.” NEJM, December 27, 2012.
2 Raven, Maria C. MD, Lowe, Robert L.MD, Maselli, Judith, MSPH, Hsia, Renee, Y., “Comparison of Presenting Complaint vs Discharge Diagnosis for Identifying “Nonemergency” Emergency Department visits.” JAMA Vol 309 No 11, March 20, 2013.   
3 Adams, James G., “Emergency Department Overuse: Perceptions and Solutions.” JAMA Vol 309, No 11, March 20, 2013
4 Lee, Michael H., MD, Schuur, Jeremiah, D. MD., Zink, Brian J., “Owning the Costs of Emergency Care: Beyond 2%” Annals of Emergency Medicine, April 26, 2013.  
5 Department of Health and Human Services, Center for Medicaid and State Operations, Director Letter to State Medicaid Directors, February 20, 1998.
6 Rand Health. The Evolving Role of Emergency Departments in the United States. May 2013.

John G. Holstein is a director of client development specializing in emergency medicine with Medical Management Professionals, Inc. (MMP).

More Articles on the Emergency Department:

Rising Acuities: The Evolution of Emergency Medicine
Can Scribes Help Improve Emergency Practice Productivity?

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