SEARCHING FOR SOLUTIONS

Many hospitals are investing in technology to better manage patient flow. Others have established urgent care centers adjacent to their EDs to care for non-urgent cases. Some, like Stony Brook University Medical Center in New York, are trying to alleviate the bottleneck by sending a limited number of admitted patients to a floor, even when there isn't a room ready for them. Peter Viccellio, Stony Brook's vice chair and clinical director of the emergency department, argues that patients are better off in unit hallways and alcoves than in an overcrowded ED where they prevent the staff from tending other patients.

"The real crisis is not what's going on with utilization, it's that we can't get admitted patients out of the ED," he says. To alleviate the ED bottleneck, "people don't need to work harder, they just need to work differently."

In Ohio, where ED visits increased 10% from 2003 to 2006, some facilities are actually expanding to compensate for hospital closings in the past decade. The Cleveland Clinic released data late last month showing that since 2005, it has cut its average ED wait times in half, from 73 minutes to 36 minutes. Wait times at the Cleveland Clinic's nine other community hospitals also fell from 64 to 43 minutes, according to the report.

The hospitals credit their reduced wait times to adding beds, a new triage system and expansion of some EDs. A new free-standing ED in a nearby suburb is currently in the works. Another Cleveland hospital, University Hospital Case Medical Center, is doubling its space by building a new $45 million ED.

To reduce sheer volume, some hospitals are trying to redirect patients with non-urgent conditions from using the ED by educating them on appropriate use. A number of hospitals, including Houston's Ben Taub General Hospital and Lyndon B. Johnson General Hospital, as well as 30 HCA Corp. hospitals in two states, tell non-urgent patients about more appropriate care outlets. If the patients choose to remain in the ED, they are charged up front and seen only after more critical patients are cared for.

Some providers are taking it upon themselves to provide that care. In September 2001, the Dallas County Medical Society and several community partners, including Baylor Health Care System in Dallas, created Project Access Dallas, a program to provide poor uninsured Dallas residents with better access to after-hours, primary care and specialty care. Within a year Baylor estimated ED usage among Project Access participants studied declined 21% and that the program saved the hospital more than $250,000 in direct costs. Today, Project Access Dallas has grown to include more than 700 volunteer physicians, 15 hospitals, nine charity health clinics, 10 ancillary service support organizations, one national laboratory service organization, and more than 40,000 nationwide pharmacies.

PAYER INFLUENCE

Private and public insurers are tackling the problem from the demand side using tools such as benefit structure, education, enhanced access to care and disease management to chip away at the problem. To discourage members from seeking non-emergent care in the ED, most plans are charging higher copays for ED care. Those copays are waived if a patient is admitted to the ED.

They're also working to improve access to care by paying for care alternatives such as e-visits and worksite and retail clinics, says Aetna Medical Director Bill Fried. In terms of education, Aetna and many other plans provide printed materials, nurse hotlines and online query services to help consumers decide when it is appropriate to seek ED care, he says.

Not surprisingly, disease management programs are a cornerstone of plans' effort to keep chronic care patients out of the ED. Some programs, such as asthma outreach efforts, have been reduced ED visits markedly. Other conditions have met with less success because they require dramatic lifestyle changes. But some argue that these efforts pale in comparison to what payers could and should be doing.

"Very, very few people go to the ER because it's a recreational event, particularly if they have health coverage," says Art Kellermann, MD, a professor of emergency care at Emory University and one of the IOM committee members. "They go because they can't get seen by their usual source of care. So the first line of attack for managed care organizations is to make sure they're adequately managing their physician networks to make sure people have access to care. That's an input variable they can control."

Working in cooperation with other payers, they can likewise force hospitals to re-engineer inefficient processes, says Arnold Milstein, MD, chief physician at Mercer and medical director for the Pacific Business Group on Health. Like many ED physicians, Milstein says hospitals need to smooth out their admission and discharge cycles.