Decreasing Emergency Department Use Is a Complex Conundrum Rustin B

Decreasing Emergency Department Use Is a Complex Conundrum Rustin B. Morse, MD, MMM,a,b Evan S. Fieldston, MD, MBA, MSHP,c,d Mark A. Del Beccaro, MDe,f

Emergency department (ED) demand findings did not vary significantly often exceeds capacity, and many, when analyses controlled for including those who provide care in insurance.3 EDs,believethatsomeEDpatients Although these findings are both should be cared for in less costly informative and important, they are non-ED settings. One common not particularly surprising, especially proposed explanation for to anyone who practices pediatric nonemergent ED use is the lack of emergency medicine. Reducing access to care, in part due to 1 unwarranted, unnecessary, or inadequate insurance coverage. aChildren’s Health, Children’s Medical Center Dallas, Dallas, inappropriate ED use is complex and b Although some policy makers have Texas; Department of Pediatrics, University of Texas multifactorial. There are many Southwestern Medical Center, Dallas, Texas; cChildren’s suggested that expanding health care reasons1,4 families may choose to Hospital of Philadelphia, Philadelphia, Pennsylvania; coverage will improve access, and dPerelman School of Medicine, University of Pennsylvania, seek care from an ED rather than an e thereby decrease ED use, others Philadelphia, Pennsylvania; Department of Pediatrics, alternative setting. From the patient University of Washington, Seattle, Washington; and fSeattle contend that there could at least be perspective, ED care can be Children’s Hospital, Seattle, Washington a transient increase in ED use by those convenient, comprehensive, who have historically deferred care.2 Opinions expressed in these commentaries are consumer centric, and sometimes those of the authors and not necessarily those of the There is also an assumption that less costly. American Academy of Pediatrics or its Committees. having insurance equals access to DOI: https://doi.org/10.1542/peds.2019-0838 primary care; however, that is not Let us look at these factors, starting Accepted for publication Mar 20, 2019 always the case. In adults, the effect of with convenience, ease of access, increased insurance coverage on ED and comprehensive service. The ED Address correspondence to Rustin B. Morse, MD, MMM, Children’s Health, Children’s Medical Center use has varied, with some efforts offers care 24 hours per day, 365 days Dallas, 1935 Medical District Dr, Dallas, TX 75235. resulting in decreases, whereas others per year. The ED does not close for E-mail: [email protected] result in increases.2 In their article lunch and does not require the PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, “ Trends in Pediatric Emergency parent or caregiver to miss work, 1098-4275). Department Use After the Affordable which, for hourly paid employees, Copyright © 2019 by the American Academy of ” 3 Care Act, Lee and Monuteaux used can result in lost wages. No Pediatrics the Nationwide Emergency appointment is necessary, but many FINANCIAL DISCLOSURE: The authors have indicated Department Sample and population EDs now offer them or some form of they have no financial relationships relevant to this estimates from the American scheduling or preregistration. By law article to disclose. Community Survey to perform (Emergency Medical Treatment and FUNDING: No external funding. a cross-sectional retrospective study Labor Act), anyone presenting for care POTENTIAL CONFLICT OF INTEREST: The authors have of ED use rates in children. They will be, at a minimum, provided indicated they have no potential conflicts of interest compared trends before and after the emergency medical treatment, even to disclose. Patient Protection and Affordable a 49-year-old with chronic back pain COMPANION PAPER: A companion to this article can Care Act (ACA), noting that after 2014, presenting to a pediatric ED. If be found online at www.pediatrics.org/cgi/doi/10. when the ACA took full effect, an laboratory testing or imaging is 1542/peds.2018-3542. additional 900 000 children obtained required, it is done without the added health care coverage.3 Before 2014, burden of preauthorization, making To cite: Morse RB, Fieldston ES, Del Beccaro MA. ED visit rates were rising by 1.1%. In additional appointments, more time Decreasing Emergency Department Use Is the post-ACA period, there was an away from work, or traveling to a Complex Conundrum. Pediatrics. 2019;143(6): e20190838 increased rise noted (9.8%), and the various other facilities for care. If the

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 143, number 6, June 2019:e20190838 COMMENTARY ED physician feels the patient has an perspective, even personally cost- ABBREVIATIONS emergent condition requiring effective. ACA: Patient Protection and subspecialty care that day, the ED ED use is complex. This Affordable Care Act will make arrangements for it to Commentary highlights a few ED: emergency department happen. This model of care, from an additional considerations beyond individual patient perspective, is expanding insurance coverage. often far more efﬁcient and Alternative care delivery models REFERENCES consumer centric than most other that can successfully compete 1. Coster JE, Turner JK, Bradbury D, Cantrell ambulatory care delivery settings. Of against the ED for patients need to course, ED visits come at a high cost A. Why do people choose emergency and develop and implement a more urgent care services? A rapid review forpayersandsometimesfor consumer-centric focus, including patients. utilizing a systematic literature search expanding hours, providing same- and narrative synthesis. Acad Emerg Although cost, in part, inﬂuences day appointments, facilitating care Med. 2017;24(9):1137–1149 behaviors, the impact it has on coordination, and incorporating 2. Sommers BD, Simon K. Health families can be vastly different. virtual visits. Health systems insurance and emergency department Patients receiving the same care in looking to decrease ED visits may use - a complex relationship. N Engl the same ED almost always end up want to consider lower-cost care J Med. 2017;376(18):1708–1711 having to pay different amounts delivery options in close proximity 3. Lee M, Monuteaux MC. Trends in depending on copays, deductibles, to EDs with access to similar pediatric emergency department use and other factors. To make matters convenient resources (eg, laboratory after the Affordable Care Act. more complex, with Medicaid, the and imaging). Finally, there needs Pediatrics. 2019;143(6):e20183542 cost of care to the patient is usually to be payment models that 4. Fieldston ES, Alpern ER, Nadel FM, Shea lower in the ED (often free). incentivize both providers and JA, Alessandrini EA. A qualitative Receiving care in the ED can patients and do not perpetuate the assessment of reasons for nonurgent therefore be convenient, current model that indirectly visits to the emergency department: comprehensive, consumer centric, incentivizes ED use for parent and health professional opinions. and in some cases, from the patient nonemergent conditions. Pediatr Emerg Care. 2012;28(3):220–225

Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 MORSE et al Decreasing Emergency Department Use Is a Complex Conundrum Rustin B. Morse, Evan S. Fieldston and Mark A. Del Beccaro Pediatrics originally published online May 22, 2019;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2019/05/20/peds.2 019-0838 References This article cites 4 articles, 1 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2019/05/20/peds.2 019-0838#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Emergency Medicine http://www.aappublications.org/cgi/collection/emergency_medicine_ sub Advocacy http://www.aappublications.org/cgi/collection/advocacy_sub Child Health Financing http://www.aappublications.org/cgi/collection/child_health_financin g_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 27, 2021 Decreasing Emergency Department Use Is a Complex Conundrum Rustin B. Morse, Evan S. Fieldston and Mark A. Del Beccaro Pediatrics originally published online May 22, 2019;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2019/05/20/peds.2019-0838

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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