More ED Patients, but Fewer On-Call Specialists Available After ACA

Two state-specific studies in Annals of Emergency Medicine provided insight into emergency department (ED) use and staffing since the implementation of the Affordable Care Act (ACA). The studies showed that average monthly ED visits increased by 5.7% in Illinois, despite flat population growth, and that in Massachusetts, the availability of on-call specialists in the ED declined significantly even as ED visits climbed steadily. In Massachusetts, at least, it has become more difficult for patients to obtain the emergency specialty care they need, that study concluded.

“Emergency departments continue to be squeezed by pressures inside and outside the hospital,” said lead author of the Illinois ED study, Scott Dresden, MD, MS, of Northwestern University Feinberg School of Medicine in Chicago.

He added the study showed a large post-ACA increase in Medicaid visits and a modest increase in privately insured visits that outpaced a large reduction in emergency department visits by uninsured patients.

“We still don’t know if these results represent longer-term changes in health services use or a temporary spike in ED use due to pent-up demand,” he said.

There was an 8.1% increase in annual ED visit volume by adults (ages 18 to 64) in Illinois between 2011 and 2015; average monthly ED visit volume increased by 5.7% when the pre-ACA period was compared to the post-ACA period studied. Notably, the size of Illinois’s population was essentially unchanged, as were the numbers of hospitalizations.

The Massachusetts ED study, by Jason L. Sanders, MD, PhD, of the Massachusetts General Hospital in Boston, and colleagues, found that between 2005 and 2014, ED consultant availability significantly declined. Consultation by non-ED physicians is an integral part of many ED visits, occurring during 20% to 60% of ED visits; however, the new study reported that ED consultations with general surgeons declined from 98% to 83%, and round-the-clock psychiatry availability declined the most alarmingly, from 56% to 33%, while availability of orthopedic surgeons, pediatricians, and plastic surgeons also declined significantly.

Sanders noted that the proportion of EDs in the state reporting any patients primarily cared for “in the hallway” climbed from 70% to 89% during the study period.

“That is far from ideal and is indicative of an increasingly taxed emergency medical care system,” he said.

While the study’s results may be limited by the fact that most data was drawn primarily from urban hospitals, the authors note that its findings should still spur further investigation of the observed associations.

“The next step of this research is to determine whether lower consultant availability is independently associated with poorer patient-centered outcomes,” the researchers wrote.

Additional research is needed into questions such as whether there has been a decline in the actual number of consultants and whether increased consultation is associated with lower rates of malpractice claims, increased patient satisfaction and safety, and whether consultation increases cost-effectiveness.

The Illinois ED study authors concluded that a large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients, and they concluded that “the changes are larger than can be explained by population changes alone and are significantly different from trends in ED use prior to implementation of the ACA.”