¶ … Health Policy Economics class. Master Degree level. It 8-12 pages long 10 resources. The topic Over-Utilization Emergency Room Services. I uploading project details. Reliance on emergency departments for non-emergent services has been on the increase with many people visiting them since they provide timely access to primary care. The 1985 Emergency Medical Treatment and Active Labor Act (EMTALA) mandated Medicare institutions to provide emergency departments for patients despite their regardless of their ability to pay for these services. Many of the uninsured or underinsured thus find these emergency rooms as the most convenience sources of health care. Overutilization of emergency rooms is a vicious cycle as a result of increasing health care costs that are associated with this phenomenon. Three possible solutions to this problem are identified which are health care homes, retail clinics and telehealth with the best solution being the health care homes.

Overutilization of emergency room services

Problem statement

Overutilization of emergency room services is one of the major causes of the increase in healthcare costs. This increase comes majorly as a result of majority of the patients seen in emergency rooms being recipients of Medicaid which is used for non-emergent purposes. Overutilization of emergency rooms has had a major impact on reforms in health care legislation and has brought about a huge debate for scholars of health and economics since health is a fundamental right for all human beings and decreasing the cost of health care is a priority for the government. There is also a vicious cycle in the overutilization of emergency room services since as more people become unable to access primary health care services, more of them are turning to these emergency department for care which is not urgent which continues to increase the cost for the emergency departments. The increase in cost of health care leads to majority of the population which is either uninsured or underinsured continuing to experience problems in paying for these high costs which creates this vicious cycle and negatively impacts the ability of these emergency departments to provide their services.

Literature review

All over the country, more citizens are visiting emergency rooms with majority of these visits comprising either the uninsured or beneficiaries of Medicaid which disproportionately affects the emergency departments which are already providing health care services to a large number of the uninsured or beneficiaries of Medicaid Jason, 2009.

In addition to this, state budgets are being cut as a result of the weakened economy causing half of all states to experience budgetary shortfalls that cause them to implement various strategies to control their Medicaid spending. Carey, Burgess, and Young (2009)

argues that a significant percentage of these visits to emergency rooms are preventable through providing timely access to primary health care as well as other programs that provide health care options for the uninsured or underinsured. These can help to improve the health outcomes and generate huge savings for emergency departments.

A study conducted in 1958 voiced concern about the increase in use of emergency departments and recommended that hospitals should plan for future increases in visits to emergency facilities. Since then, the number of visits to emergency rooms has increased by more than 600% Smith et al., 2005.

Over the last two decades, scholars have voiced their concern on the dramatic increase in visits to emergency room departments which many analysts of health care policies stating that this increased utilization of emergency rooms negatively impacts health policy since majority of these visits to emergency rooms are non-emergent McWilliams, 2009.

This led to the argument that emergency rooms were becoming less effective in the health care sector since they are forced to work towards limiting the access of patients to emergent care Moon & Shin, 2005()

The Emergency Medical Treatment and Active Labor Act (EMTALA) which was enacted in 1985 created obligations for all organizations participating in Medicare programs to provide their patients with medical screening examinations regardless of their ability to pay for these services. This act has since been revised, reinterpreted and increasingly enforced leading to expanded availability of emergency departments. The law also specified the scope of the medical screening examination to increase routine ancillary services such as consultation and inpatient services where needed. This act guaranteed patients they had a place to seek medical care despite the situation of current health care reforms. Scholars have argues that EMTALA is a major economic hurdle for many health care organizations since it mandates them to provide these services without any reimbursement from the government. Miller (1993)

The economic burden on emergency departments is made worse by the insufficiency of Medicare reimbursement which is unable to cover the direct costs of the facility Jones, Reilly, & Broyles, 1992.
Medicaid reimbursement also worsens the situation since most services are reimbursed at between 30 and 50% less than Medicare which widens the funding gap for Medicaid recipients who form majority of the population McFarlane & Prado, 2002.

These financial stresses on health care facilities have led to the closure of more than 500 hospitals and 1000 emergency departments over the last 10 years Dranove, 2008()

In addition to this, the number of uninsured people has continued to grow as a result of great poverty. It is approximated that there are over 45 million uninsured people in America with 15 million being children till the age of 21 years. The elderly also form a significant percentage of the uninsured. Homeless people and other living on or below the poverty line also stand at about 15 million and are all uninsured Olson, 2010.

Though the Medicaid program has strived to increase access to quality primary care, the program has shorten fall of its goals since a line has been draw between Medicaid beneficiaries and the uninsured who remain the majority Lambrew, Gordon, Carey, Ricketts, & Biddle, 1996()

Problem analysis

Major reasons for overutilization of emergency room services

Emergency room visits are on the rise as a result of reduced inpatient capacity in major hospitals as well as impaired flow of patients. The National Center for Health Statistics states that in the year 2004, there was an 18% increase in the number of emergency department visits over the previous 10-year period while at the same time hospitals experienced a 12.4% decrease in the number of hospital emergency departments. The Institute of Medicine also adds that visits to emergency departments grew more than twice as fast as the growth in population between the years 1993 and 2003 which caused more than 60% of the hospitals offering emergency room services to run at or over their capacity.

Increase in chronically ill or elderly citizens is one of the major factors contributing to the rise in emergency room visits. The second factor as identified by Thibadoux, Scheidt, and Luckey (2007)

is overworking or lack of physicians providing primary care. This is also coupled with the lack of primary care outside the normal business hours of any facility. As a result of their being few physicians providing primary care, there are longer wait times for appointments with physicians which has pushed majority towards emergency rooms. Tanne (2007)

also argues that high use of emergency rooms for problems that are not urgent is also driven by habit and preference. Lowe et al. (2005)

also adds that statistics of those receiving outpatient services in emergency rooms do not show any differentiation in the income, insurance, race or ethnicity of the users.

Privately insured people also contribute to increased emergency room visits. This is because they account for half of the increase in these visits as they continue to make fewer visits to primary care physicians. In the study conducted by Grieb and Clark (2008)

, it was found that 17.5% of all visits for ambulatory care were by beneficiaries of Medicaid which was compared to 7.6% of the privately insured. This has since risen to 25% for the uninsured, 50% for Medicaid beneficiaries and 75% for the privately insured. Overall, the lack of primary care providers is the leading cause of increase in utilization of emergency rooms services.

Are these increased visits to emergency rooms avoidable?

Bristol (2006)

argues that about 35% of all visits to emergency rooms are avoidable since they are ambulatory care sensitive (ACS) or non-urgent which makes them treatable in primary care hospitals. However, Blackstone, Buck, and Simon (2007)

argues that the percentage of avoidable visits is even higher. Studies by the National Center for Health Statistics show that 55% of all visits to emergency rooms are avoidable and two further studies conducted in Utah found that 44% of all visits to emergency rooms were primary care sensitive and roughly 40 -- 60% of all visits to emergency departments made by children were non-urgent. Beneficiaries of Medicaid and the uninsured form the majority of these avoidable visits.

High costs of avoidable visits to emergency rooms

Brailsford, Lattimer, Tarnaras, and Turnbull (2004)

argues that emergency room services are more costly than primary care services because they charge about two to five times what is charged for typical visits to private physicians. The National Association of Community Health Centers…