"Emergency" overload

The "free" end of U.S. health care shows the usual symptoms

Demand for emergency department (ED) services at U.S. hospitals is surging. As a result of this upsurge, EDs are confronting a crisis. They do not have the capacity to deal with rising demand. Due to federal regulations that require EDs to treat any patient who enters, hospitals have struggled to manage such overcrowding. Overcrowding is most often attributed to the inability of emergency departments to transfer admitted patients to inpatient beds, according to a report by the Government Accountability Office. Therefore, hospitalwide capacity problems are driving overcrowding in EDs. There are two causes of this phenomenon:

1. Supply. Supply-side factors have exacerbated overcrowding:

-- Efficiency measures. In response to the pressures of managed care and lower reimbursement from Medicare and private payers over the past 15 years, hospitals have reduced their number of beds to improve efficiency. Hospitals have also closed less profitable units or converted them to specialized units, leaving less overall inpatient capacity to absorb ER admissions.

-- Nursing shortages. Even hospitals that have enough beds often suffer from staffing shortages.

-- Discharge. Skilled nursing facilities and home health services have seen a decrease in investment and are facing financial problems, resulting in fewer discharge options. This puts further strain on inpatient capacity.

2. Demand. Factors on the demand side are also fueling the overcrowding problem:

-- HMO management. A political backlash against health maintenance organizations (HMOs) in the late 1990s led to a relaxation of their policies on emergency care, which stimulated more ED use by HMO patients.

-- EMTALA. The Emergency Medical Treatment and Active Labor Act requires ambulance services and hospitals that receive Medicare reimbursement to provide emergency care to anyone.

-- Aging population. As baby boomers grow older and sicker, demand for emergency care is increasing.

-- Non-emergent visits. Less than half of all emergency visits are classified as "emergent" or "urgent."

-- Increased utilization. Many policymakers assume that the rising number of uninsured people is primarily responsible for driving the crisis. However, a recent study by the Center for Studying Health System Change concludes that most of the increase in ED use is due to more visits by insured patients.

Overcrowded EDs have several deleterious effects on patients and hospitals:

-- Lower perceived quality. Higher waiting times for examination and admission leave patients less satisfied with treatment.

-- Compromised care. EDs are primarily designed for emergency care. Non-emergent visits detract from this task.

-- Costs. ED treatment is expensive, relative to other ambulatory services. Increases in non-emergent visits to the ED raise costs that may spill over to all patients.

Capacity constraints highlight other related challenges facing the U.S. health care system, including:

--unchecked demand and overconsumption of health services among the insured; and

--inadequate access to primary care for the uninsured.

Individual hospitals are attempting to address issues of overcrowding by expanding EDs and raising efficiency. This should help in the short term. However, in the long run, more fundamental reform will be needed. The ED experience shows that the alternative of universal insurance coverage will not solve problems of demand. Market-oriented approaches, in combination with government-led reforms, may offer a more comprehensive solution.

The ED capacity crunch highlights the chronic problems of unchecked demand, overconsumption created by the third-party payer system of heath insurance and inadequate access to primary care by the uninsured. The pressure for a more concerted legislative attempt to reform the system will grow during the 2007-2008 Congressional term.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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