RAND Report: Despite High Costs, Emergency Departments Serve Vital Community Needs

In a study entitled “The Evolving Role of Emergency Departments in the United States,” commissioned by the Emergency Medicine Action Fund, RAND Health looked at how emergency departments (EDs) contribute to our modern health care system and how it can be better integrated with community care. Since their inception following World War II, the importance of EDs has grown since medicine became more hospital-based. Now EDs are vital to the delivery of acute ambulatory and inpatient care, and will continue to evolve in response to economic, clinical, and political pressures, the study observed. The fact that charges for minor illnesses and injuries are higher than other types of non-urgent care, however, have caused policymakers to blame EDs for the grown in spending.

Although frequently described by policymakers as “the most expensive care there is,” EDs only contribute minimally to spending growth. EDs act as gatekeepers to inpatient care, and that is where the spending growth is rising. Further, EDs provide crucial care to members of the community, partly because they are statutorily required to provide care to all of those in need regardless of their ability to pay.

As part of the study, RAND (1) looked at literature regarding ED use, (2) analyzed four datasets compiled and maintained by HHS and data from the Community Tracking Study (which describes changing patterns in health care utilization and delivery), as well as (3) conducted focus groups with emergency medicine physicians and hospitalists and interviewed primary care physicians. The study’s key findings include:

  • Office-based physicians seem to be directing patients to EDs rather than admitting them to hospitals, since inpatient admissions grew at a slower rate than the population between 2003 and 2009, but there was a 10 percent decrease in admissions from doctor’s offices while there was a 17 percent increase in unscheduled admissions from EDs.
  • EDs support primary care by handling diagnostics and overflow, after-hours and weekend care.
  • Emergency physicians are more often acting as decisionmakers for around half of all hospital admissions, which nets more revenue for hospitals since the bulk of their revenue comes from admissions.
  • Most patients arriving in an ED walk in the front door and walk out the same way, yet most of these patients do not seek care in EDs for convenience—they believe no viable alternative exists for them.
  • Medicare accounts for more inpatient admissions from EDs than from any other payer.
  • EDs may be reigning in the growth of inpatient admissions.

The study suggests that EDs are an important source of hospital admission, are being used to help with diagnosis for patients for primary physicians, are the best option for patients with non-emergency outpatient care because of a lack of timely options elsewhere, and may even be preventing some admissions.

RAND Health is a part of the RAND Corporation, a nonprofit institution charged with helping to “improve policy decisionmaking through research and analysis.” The Emergency Medicine Action Fund is a consortium of emergency medicine physician organizations sponsored by the American College of Emergency Physicians.