How Safety-Net ERs Can Save Health-Care Reform

In the coming years of health-care transition, county-hospital ERs will continue to be the first refuge for America's marginalized and vulnerable populations. They must evolve to become coordinating centers for society's health needs and champions of cost reform.
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Safety-net emergency departments are frequently blamed for being the source of rising health-care costs. After all, they care for the millions of underserved and uninsured Americans forced by a variety of circumstances to visit ERs for their primary care and low-acuity concerns.

With the Affordable Care Act (ACA) reforms initiated in January, demand for emergency services will rise significantly. Medicaid already covers over 50 million individuals, most of whom are vulnerable low-income children and their mothers, or medically complex elders. Now that Medicaid has been expanded to those earning up to 138 percent of the federal poverty level in many states, new research predicts that previously uninsured patients will use emergency services even more frequently. Furthermore, the Center for Medicare & Medicaid Services will reduce disproportionate-share-hospital funding (a major revenue source for safety-net providers) from now until 2020 to accompany the ACA expansion. States that did not expand Medicaid coverage will likely struggle to provide services to their underserved patients.

However, recent evidence highlights the ER's success in making one of the most cost-effective decisions in health care: whether or not to admit patients to the hospital. By streamlining diagnosis and treatment of critical illness and the complications of chronic disease, ERs can prevent unnecessary admissions, where inpatient costs such as basic maintenance and diagnostic imaging rise rapidly.

Safety-net ERs can be important driving forces in increasing health-care value and improving patient care -- but in order to do so, they must tailor cost-saving strategies to their communities' most pressing needs. This can be achieved with regionally focused ER-based research that explores the social determinants of illness, alongside a multidisciplinary approach to emergency care that tackles non-medical factors contributing to adverse health outcomes.

ER-based research can expose the social issues -- such as food insecurity, unstable housing, and local violence -- that are at the root of patients' illnesses leading to ER visits and hospitalizations. For example, the Levitt Center for Social Emergency Medicine, a collaboration between the University of California Berkeley School of Public Health and emergency physicians at Alameda Health System in Oakland, explores how unemployment in California affects patterns in ER and ambulance use. The researchers have found that when populations lose their housing, employment, or health care as a result of economic downturn, there are increased patient visits for substance abuse, psychological stress and chronic disease care. They hope to leverage their research to affect local policy and influence upstream primary-care interventions.

In the delicate transition toward health reform, safety-net ERs can serve as hubs for access to essential non-medical services such as housing assistance, social work, mental health, and legal advocacy for lower-income individuals. It is well established that interventions that address personal behavior, social circumstances and environmental factors affect a greater proportion of poor disease outcomes compared with medical care alone.

The Highland Health Advocates (HHA) in Oakland started a patient help desk in the waiting room of their busy county ER, facilitating enrollment in health coverage plans and providing social services and legal counsel to patients who are often undocumented and uninsured. Other health-resource-desk models around the country have shown success in resolving crucial unmet needs for patients and their families. Until patient-centered systems are streamlined, safety-net hospitals and programs like HHA may be best positioned to address the social and behavioral issues that prevent patients from accessing the services that they qualify for but that require complicated paperwork and long wait times to access.

Emergency departments occupy a unique position in American health care: so close to the poorest communities, yet at the doorway to the most expensive interventions of modern medicine. In the coming years of health-care transition, county-hospital ERs will continue to be the first refuge for America's marginalized and vulnerable populations. They must evolve to become coordinating centers for society's health needs and champions of cost reform, or underserved patients will continue to fall through the cracks of the current system.

Without addressing social needs, health-care access, and payment reform in parallel, America simply cannot bend the health-care-cost curve. Emergency rooms are a good place to start.

This post originally appeared on KevinMD on March 15, 2014.

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