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Health Affairs Examines The State Of Emergency Medicine


December articles explore "mission versus reality" in this ACA neglected practice area


Bethesda, MD -- The December issue of Health Affairs examines the state of emergency care in the United States. As Founding Editor John Iglehart describes in the issue: "Emergency departments seem like orphans in the US health care system, with few strong allies among policy makers; as an afterthought in the Affordable Care Act...long popularized by television dramas but less recognized for the expanding array of activities in which its practitioners are engaged."


This theme issue, titled "The Future of Emergency Medicine: Challenges & Opportunities," explores and explodes these myths. It received support from the Hospital Corporation of America; the American Hospital Association; the American College of Surgeons; the Emergency Medicine Action Fund, a consortium sponsored by the American College of Emergency Physicians; the American College of Emergency Physicians; the Jewish Healthcare Foundation; the Society for Academic Emergency Medicine; and MEP.

Several articles in the issue will be discussed at a December 4 Health Affairs briefing in Washington, D.C.



How an emergency department resembles Grand Central Station. Arthur Kellermann, dean of medicine at the Uniform Services University of the Health Sciences, and coauthors provide an issue overview, succinctly tracing the history of emergency care since World War II and looking ahead to the emergency departments of the future. "Like Grand Central, modern hospital emergency departments (EDs) are constantly in motion," writes Kellermann. "And, like Grand Central, EDs have purposeful order beneath their superficial chaos." Kellermann sees today's emergency departments as centers for lifesaving care and resources for disaster as well as the "safety net of the safety net" for millions of low-income and uninsured patients. To succeed in the future, Kellermann says that emergency care must become more integrated, regionalized, prevention oriented, and innovative.


Dispelling the urban legend of emergency department 'frequent fliers.' The Emergency Medical Treatment and Active Labor Act (EMTALA) guarantees all Americans the right to emergency medical care. This mandatory role has led to a common misperception that emergency rooms are frequented by a small number of patients-mentally ill substance abusers, whose frequent use of emergency departments are a costly drain on the health care system. However, John Billings of NYU Wagner and Maria Raven of the University of California, San Francisco, paint a different picture of these ED "frequent fliers." They analyzed over 200,000 Medicaid feeforservice claims from New York City in 2007 and found that behavioral health conditions are only responsible for a small portion of these users, accounting for less than 8 percent of all ED visits. What they found was that frequent users are quite sick, often with multiple comorbidities. Through predictive modeling, the authors maintain, emergency departments can determine who the repeat users will be and can target interventions to reduce their unnecessary visits.


Want to reduce health care costs? Increase emergency department observation units. Many patients seeking emergency department treatment fall into a gray zone: They're not well enough for immediate discharge but not sick enough to be admitted as a hospital patient. Michael Ross of Atlanta's Emory University and Grady Memorial Hospital and coauthors compared patients cared for in "type 1" observation units dedicated observation units with defined treatment protocols using 2010 data from local, state, and national clinical settings. The authors found that observation patients in "type 1" units have a 23-38 percent shorter length of stay, a 17-44 percent lower probability of subsequent inpatient admission, and $950 million in potential national costs savings each year. They also found that these units could avoid 11.7 percent of inpatient admissions, saving the United States $5.5-8.5 billion annually. This level of treatment, conclude the authors, gives emergency department physicians a better option to care for the increasing portion of patients who are not sick enough to warrant inpatient care.


  • In a study on a related topic, Jesse Pines of the George Washington University and coauthors examine how providers and organizations can reduce acute care costs without sacrificing quality. Reducing demands for acute care, they suggest, may be achieved through public health measures and educational initiatives. It will also be necessary to change providers' behavior, through the development of care pathways and other tactics such as providing feedback. The authors maintain that fee-for-service payment with new incentives, based on as yet undeveloped resource and quality measures, is the only feasible approach to paying for acute care.


Also in the December issue:



  • Creating Integrated Networks Of Emergency Care: From Vision To Value, Ricardo Martinez of North Highland Worldwide Consulting and Brendan Carr of the University of Pennsylvania and the Department of Health and Human Services

Care for Specialized Populations:

  • A Promising Approach For Emergency Departments To Care For Patients With Substance Use And Behavioral Disorders, Steven Bernstein and Gail D'Onofrio of Yale University

  • Emergency Care For Children In The United States, James Chamberlain of the George Washington University and Children's National Medical Center and coauthors

  • Transforming Emergency Care For Older Adults, Ula Hwang of Mount Sinai and coauthors

Some Global Lessons:

  • Learning From Japan: Strengthening US Emergency Care And Disaster Response, Parveen Parmar of Brigham and Women's Hospital and coauthors

  • On Constant Alert: Lessons To Be Learned From Israel's Emergency Response To Mass-Casualty Terrorism Incidents, Brunia Adini of Israel's Ben-Gurion University of the Negev and Kobi Peleg of the Gertner Institute and Tel Aviv University
About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically at The full text of each Health Affairs Web First paper is available free of charge to all website visitors for a one-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download our podcasts, including monthly Narrative Matters essays, on iTunes. Tap into Health Affairs content with the new iPad app.