ED 'crisis'

Ranks shrink by 27% despite spike in visits

The number of hospital EDs, especially those serving large indigent patient populations, is dropping "at an alarming rate," while emergency visits continue to rise, according to a study in this week's JAMA.

Using American Hospital Association (AHA) data and Medicare cost reports, University of California-San Francisco researchers and colleagues analyzed hospital ED closures and openings from 1990 to 2009. They found that more than 1,000 EDs closed and only 374 opened during that period. Overall, the number of hospital EDs in urban areas fell from 2,446 in 1990 to 1,779 in 2009, marking a 27% drop. At the same time, hospital ED visits rose by 35%.

The findings showed that about 66% of ED closures occurred when a hospital closed, while the rest closed when the hospital stayed open. EDs with low profit margins and those at for-profit facilities were nearly twice as likely to close as other EDs. According to the study, hospitals that served a disproportionately high number of Medicaid and low-income patients were 40% more likely to close their ED, suggesting that low insurer reimbursement may have been a factor. Meanwhile, hospitals in the nation's most competitive markets were about 30% more likely than other hospitals to shut their EDs. For example, New York City hospitals closed seven EDs from 2008 to 2010, the New York Times reports.

Calling the trend a "continuously deteriorating situation," the study's lead author said the findings underscore that "market forces very much are at play in our healthcare system," noting that a market-based approach may not ensure that resources are distributed evenly.

Many industry experts say ED demand may increase after implementation of the federal health reform law, which will expand Medicaid eligibility. According to the president of the American College of Emergency Physicians, Medicaid patients often turn to EDs for care when physicians do not accept their coverage, and EDs are required by law to treat every patient regardless of their ability to pay (Rabin, Times, 5/17; Barr, Modern Healthcare, 5/17 [subscription required]; Gardner, HealthDay, 5/17; Joelving, Reuters, 5/17).

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