ED Physicians Key to Half of Hospital Admissions

Doctors in the emergency department are the major decision makers in nearly half of all hospital admissions, giving them a significant role in controlling healthcare costs, research shows.

Jay A. Kaplan, MD, has been an emergency physician for more than 30 years and over the decades he has witnessed firsthand what he says is the evolving role of the emergency department in providing frontline healthcare.

"When I first started practicing we called it the emergency room," Kaplan says. "Then we got called the emergency department. We have morphed again. We are no longer an emergency department. We are an emergency care and acute diagnostic center."

Kaplan, a board member with the American College of Emergency Physicians, points to a Rand Corporation study commissioned by the Emergency Physician Action Fund which shows that emergency physicians are key decision makers for nearly half of all hospital admissions. Because of that, Kaplan says, emergency physicians are playing a critical role in controlling healthcare costs.

RAND found that hospital admissions from the ED increased 17% over seven years, accounting for nearly all the growth in hospital admissions between 2003 and 2009, offset by a 10% drop in admissions from primary care physicians and clinical referrals. Nearly all of the increase was from "non-elective" admissions from the ED—a rate 3.8 times the rate of population growth.

Hospital inpatient care is a key driver of healthcare costs, accounting for 31% of the nation's healthcare expenses. Because of that the role emergency physicians play in deciding who to admit to the hospital is critical to hospital cost savings, since the average cost of an inpatient stay ($9,200) is roughly 10 times the average cost of a comprehensive emergency visit ($922), RAND said.

"Use of hospital emergency departments is growing faster than the use of other parts of the American medical system," Art Kellermann, MD, the study's lead author and a researcher at RAND, said in prepared remarks. "While more can be done to reduce the number of unnecessary visits to emergency rooms, our research suggests emergency rooms can play a key role in limiting growth of preventable hospital admissions."

Kaplan says RAND shows that office-based physicians are directing some patients to the ED who they previously would have admitted themselves. The study also found that EDs perform complex diagnostic workups that cannot be done in primary care physicians' offices, and that EDs supplement primary care providers by handling overflow, after-hours cases and weekend call.

"Patients who come to the ED are coming either because they have been sent there by their private doctor, or they have no other healthcare provider to turn to," Kaplan says. "Even those who have primary care doctors, when they call them for an appointment, they say 'go to the ED.'"

Rather than a focus on keeping people out of the ED, Kaplan says the emphasis should be on providing EDs with the resources they need to successfully adapt to this new trend.

"That includes more widespread adoption of inter-connectability and interoperability of (healthcare information technology)," he says. "If the doctors have the patient in the ED from a skilled nursing facility, if I can access the patient's history and medications and allergies and test results that helps a lot. The more collaboration, the more we can create effective transitions of care."

"Care handoffs are crucial. Rather than seeing the ED as the more expensive place to receive care, they should be viewed as acute diagnostic centers that provide clinically and economically efficient ways to evaluate complex patients with worrisome symptoms."

Two weeks ago the American Hospital Association came out with its own report that showed that EDs are treating growing numbers of sicker Medicare patients who require more complex and expensive treatment regimens. AHA says data show that between 2006 and 2010, the severity of illness of Medicare patients in the emergency department increased, as did the rate of use, a trend that policymakers fear is leading to higher spending with inadequate reimbursements.

The AHA says the federal government's more stringent inpatient admissions guidelines and growing claims denials are also putting more pressure on hospitals to treat Medicare patients in the ED rather than admit them.

The RAND report found that increased admissions were highest among people ages 65 and older. 

"If you look at the increase in admissions, what you see is that it has more to do with the aging population," Kaplan says. "Patients are being sent to the ED with their acute illnesses and with their complex illnesses. Admissions to the ED are 50% of all hospital admissions and 70% of all non-elective admissions. One of the things that we do know is that it is the Medicare patients, the sicker patients, who are admitting. When I first started practicing, if you saw an 80-year-old, that was relatively rare. These days probably half the patients I see are 80 or 90 and with more complex illnesses too."

"It's a function of an aging population and it is a function of the workforce shortage, particularly among primary care physicians," Kaplan says.

"And the truth is it also relates to the fact that there are many primary care physicians and other physicians who will not take Medicaid and for that matter will not take Medicare. They only want patients with private insurance."