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Reimbursement-related pressures on emergency medical care

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  • 1. EMERGENCY!!! in the Emergency Department Ashley Killinder, PA-S University of Kentucky, 2008
  • 2. Objectives…
    • History of Emergency Department (ED)
    • Reasons for Overcrowding in the ED
    • Solutions to the Problem
    • Questions and Answers
  • 3. History…
    • The first American hospital was established in 1752.
      • Patient Care = Free!
    • For-profit hospitals in 1900’s
      • Patient Care = Expensive!
  • 4. History…
    • The introductions of Medicare, Medicaid, HMOs, and DRGs in 1970s-80s.
      • Patient Care = Free for some, expensive for others.
    • National Hospitals 2007
      • Administration Corruption
      • Abuse of the System
      • Collapse of Infrastructure
  • 5. Shocking Statistics…
    • 90% of Nation’s large hospitals operate Above Capacity
    • In the past 10 years, the number of patients seen in the ED has risen 26%, while population has grown only 11%.
    • In the past 5 years, the number of Medicaid patients seen in ED risen 23%.
  • 6. How is the ED compensating?
    • They are not!
    • In the past decade, 500 EDs have been closed, 1/3 of those in rural populations.
    • There is currently a 114,000 bed shortage in hospitals nationwide.
    • The US is currently in a state of Nursing Shortage as large numbers are leaving the medical field.
  • 7. Why should we care?
    • The Emergency Department is the sole Safety Net healthcare provider in the US.
    • Since 1986, Federal Law requires the ED to treat all patients, regardless of the ability to pay.
    • Collapse in the ED  Collapse of US healthcare system
      •  Saturation of patient care outside the hospital.
  • 8. The Bottom Line
    • The Emergency Department is in a state of Emergency!!!
    • Caused by:
      • Decreased Bed Availability
      • Increased Numbers on Medicaid
      • Outflux of Hospital Staff
  • 9. Methods
    • The information presented today is based on data collected via PubMed .
    • The data is construed from 17 core articles, the majority of which were conducted research studies within the past five years.
  • 10. Define Overcrowding…
    • How crowded is too crowded?
      • National ED Overcrowding Study (NEDOCS)
      • Trzeciak and Rivers
    • Quantitative rather than Subjective
      • Putting patient numbers makes more of a statement than personal judgment of overcrowding in the ED
  • 11. Increased Numbers
    • Which population contributes the most to the overcrowding problem in the ED?
      • Uninsured patients ?
      • Medicaid patients ?
      • BOTH ?!
  • 12. Increased Numbers: Ethnic, low-income, uninsured populations
    • Communities with higher levels of…
      • Low-income
      • Racial/ethnic minorities
      • Immigrant residents
      • Uninsured population
    • … were NOT the communities with the highest numbers of ED visits.
  • 13. Increased Numbers: Influx of Medicaid/SCHIP
    • Populations with highest numbers of ED visits = highest number of Medicaid enrollees.
    • The average Medicaid patient has 16 more ED visits than the average uninsured patient.
  • 14. Who is at Fault?
    • Are Medicaid patients the “Bad Guy”?
    • Look out for large cuts in Medicaid/ SCHIP funding
  • 15. Outflux of Staff
    • Increased patient numbers = increased responsibility
    • 2004 NEDOCS questionnaire:
      • 1. Qualify the degree of overcrowding
      • 2. If the staff felt rushed
      • 3. Quantify the degree of overcrowding
    • Patient : Staff ratio
      • Overcrowding = Unsafe!!!
  • 16. Solutions
    • Donated Care Program
      • Local physicians provide pro bono work
      • Hospitals contribute $20,000/year toward free community healthcare.
    • Employeeing Mid-Level Providers
      • Physicians Assistants are cost effective, skilled, and on the rise in the ED.
      • 47% of EDs use PAs in the ED
  • 17. Conclusion
    • The ED is in trouble, reflecting a problem on the entire healthcare system.
    • Solutions to the problem must be initiated at every level of care.
    • Local communities provide hope for restoration.
    • Utilization of PAs eases burdens in ED.
    • Action must start NOW!
  • 18. References
    • Barlett DL, Steel JB. Critical condition: how healthcare in America became big business and bad medicine. New York (NY): Doubleday; 2004.
    • Brewer C, Kovner CT. Is there another nursing shortage? What the date tells us. Nursing Outlook. 2001 Jan; 49(1):20-26.
    • Brewster LR, Felland LE. Emergency department diversions: hospital and community strategies alleviate the crisis. Issue Brief Cent Stud Health Syst Change. 2004 Mar;(78):1-4.
    • Congress of the United States. Diagnosis related groups (DRGs) and the medicare program: implications for medical technology – a technical memorandum. Office of Technological Assessment. 1983 Jul: 23-25.
    • Cowan RM, Trzeciak S. Clinical review: emergency department overcrowding and the potential impact on the critically ill. Crit Care. 2005 Jun;9(3):291-5.
    • Cunningham PJ. Medicaid/SCHIP cuts and hospital emergency department use. Health Aff (Millwood). 2006 Jan-Feb;25(1):237-47.
    • Cunningham PJ. What accounts for differences in the use of hospital emergency departments across U.S. communities? Health Aff (Millwood). 2006 Sep-Oct;25(5):324-36.
    • Dorsey JL. The health maintenance organization act of 1973 and prepaid group practice plans. Med Care. 1975 Jan;13(1):1-9.
  • 19. References
    • Eastaugh SR. Overcrowding and fiscal pressures in emergency medicine. Hosp Top. 2002 Winter;80(1):7-11.
    • Ganapathy S, Zwemer F. Coping with a crowded ED: An expanded unique role for midlevel providers. Am J Emerg Med. 2003 Mar;21(2):125-128.
    • O’Malley AS, Gerland AM, Pham HH, Berenson RA. Rising pressure: hospital emergency departments as barometers of the health care system. Issue Brief Cent Stud Health Syst Change. 2005 Nov;(101):1-4.
    • Oswanski MF, Sharma OP, Raj SS. Comparative review of use of physician assistant in a level I trauma center. Am Surg. 2004 Mar;70(3):272-9.
    • Taylor EF, Cunningham P, McKenzie K. Community approaches to providing care for the uninsured. Health Aff (Millwood). 2006 May-Jun;25(3):173-82.
    • Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003 Sep;20(5):402-5.
    • U.S. Department of Health and Human Services. EMTALA: emergency medical treatment and labor act. Center for Medicare and Medicaid Services. 2006 Oct, Available on: http://www.cms.hhs.gov/FACA/07_emtalatag.asp .
    • Weiss SJ, Derlet R , Arndahl J , Ernst AA , et al. Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med. 2004 Jan;11(1):38-50.
  • 20. Questions?…

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