As one of the principal authors of the original Emergency Medical Treatment and Active Labor Act (EMTALA), I want to make clear that our efforts as the advisors to Senator Kennedy’s Committee in 1985 were squarely focused on the responsibility of hospital emergency departments (EDs) to provide access to emergency care within their communities. Representative Stark in the House of Representatives agreed unequivocally with Senator Kennedy about this point and together they helped enact the “anti-dumping” bill with bipartisan support. Nevertheless, it took years of additional work before EMTALA began to make a real impact. Access problems may have changed since EMTALA barred “dumping,” but inadequate access to care remains a problem.
The intent of EMTALA was never to make EDs a major provider of outpatient care. However, as documented in the December issue of Health Affairs, EDs now provide a significant percentage of all acute care visits for the uninsured. Many of the people who rely on EDs as a source of outpatient care lack access to the bedrock foundation of a rational health system—a primary care home. Some have no regular source of care, some do not know where to go for a medication refill, and some feel they have no other way to find reassurance or safety when panicked about their wellbeing. In particular, finding urgent mental healthcare remains a significant challenge for many. But, thirty years after the passage of EMTALA, the nation is slowly moving to address the access problem. The seeds of a solution are scattered around the country. They must grow and spread if they are to coalesce into a full-blown remedy.
What follows are some key elements necessary to continue improving access to primary healthcare while assuring that investments in emergency care are appropriately utilized.
Patient-centered medical homes. The enhanced version of primary care that is offered by health teams working in patient-centered medical homes (PCMHs) is one part of the solution. PCMHs provide access to care on a 24/7 basis with the following special features:
- Open access: allows people to see their primary care provider on the day they call or the next day
- Care manager: nursing staff who help people manage chronic conditions thereby reducing ED visits
- Transition care: helps reduce hospital readmissions, which typically include ED visits, by encouraging discharged hospital patients to follow up with their primary physician in the next few days
Health reform. By supporting an increase in the number of community health centers, and establishing more widespread coverage by health insurance, health reform is expanding access to outpatient care. Community health centers have been shown to decrease ED use in their communities. Hospitals that have worked to establish ongoing relationships between primary care physicians and ED patients have also decreased ED use.
Health Information Exchanges (HIE). The HIE in Delaware permits hospital EDs and other medical providers throughout the state to save time and money by sharing patient data stored on “back-end” servers that secure and hold patient medical information, and reduce the need to repeat costly diagnostic imaging and lab testing. They provide emergency clinicians and other providers with quick summaries of patient diagnoses, tests, and prescribed medications. The efficiencies from HIEs are real; reports on cost savings are not yet verified.
Analyses of emergency room usage. Data leads to clarity about the nature of the problem, and helps shape solutions. Careful analysis can lead to groundbreaking cost saving innovations like in Camden, NJ, where analysis led to the discovery of “super utilizers” with hundreds of ED visits per year. Many such individuals had mental illness or homelessness as well as chronic disease. Their needs were addressed by accessible and appropriate care such as nurse practitioners or physician assistants placed at convenient access locations closer to home like apartment buildings or shelters. Such appropriate care reduced ED use and essentially paid for itself with the money that was saved through diminishing ED misuse.
Taken together, these approaches could solve many of the problems of urban EDs. One more piece of the puzzle is still missing though: this is strategic collaboration between providers, public health departments, and local or state governments – all of which have a stake in repairing the overloaded and inefficient emergency care system. This collaboration should be based on transparent data and joint accountability. Public and private financial incentives or stimuli could help. Federal demonstration funding has supported the formation of HIEs.
Increased support for analyses of ED data in the context of collaborative and transparent work by multiple stakeholders with planning grants could push the agenda further. This cooperation between stakeholders in the same “medical neighborhood” will allow these solutions to disseminate and build toward rational systems that care for the patient with the right clinician in the right place at the right time.