In Pennsylvania, as across the U.S. as a whole, emergency medicine constitutes an essential strut in the support of a health care system that is increasingly overtaxed and underfunded. Nationally, in 2010 there were 129.8 million emergency department visits, or 42.8 visits per 100 persons, of which 13.3 percent resulted in hospital admission, according to Centers for Disease Control and Prevention data. Of the more than 110 million patients who were seen in the ED and not admitted to the hospital, the majority not only had health insurance, but also had a health care provider that they would identify as a source of primary care. For many of these insured patients, ease of access, relative speed of care (compared to primary care office visits), and patient perceptions of quality in a hospital-based resource-rich environment are principal drivers of ED utilization. For uninsured patients, the ED often represents their only available venue in which to receive health care. Yet, emergency medicine accounts for only 2 percent to 4 percent of the nation’s total health expenditures, according to AHRQ data.
By virtue of statutory regulations that require type A emergency departments to provide unscheduled care 24 hours a day, 365 days a year, EDs represent an irreplaceable part of the health care safety net for all patient categories. Further, due to the obligation to remain constantly staffed and available, the marginal cost (the cost of seeing the next case) of ED care is often less than that incurred in other venues. While hospital (facility or “technical”) component fees typically drive up the cost of emergency care, professional fee billing by emergency physicians is generally in line with that of office-based providers for similar levels of evaluation and management (E/M) services. Moreover, it must be recognized that the E/M services provided in an ED quite often serve to obviate “unnecessary” hospital admissions; in such circumstances, the care provided in the ED, often characterized as “expensive,” nonetheless represents considerable cost savings when compared to the expense of hospital inpatient care.
Medicaid enrollees of all age groups use EDs as a source of episodic care. There is evidence that Medicaid beneficiaries may use the ED more frequently than non-Medicaid patients. However, recent study has demonstrated that most Medicaid usage of EDs is appropriate, and related to more serious or urgent complaints.
Under the provisions of the Patient Protection and Affordable Care Act (ACA), Medicaid enrollment for all age groups is expected to increase by 16 million over the next decade. Included in this expansion would be a rise in the number of Pennsylvania CHIP beneficiaries, currently reported as 187,634 statewide as of April 2013, according to Pennsylvania Insurance Department data.