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entitled 'Hospital Emergency Departments: Health Center Strategies 
That May Help Reduce Their Use' which was released on May 11, 2011. 

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United States Government Accountability Office: 


Before the Subcommittee on Primary Health and Aging, Committee on 
Health, Education, Labor, and Pensions, U.S. Senate: 

For Release on Delivery: 
Expected at 10:00 a.m. EDT:
Wednesday, May 11, 2011: 

Hospital Emergency Departments: 

Health Center Strategies That May Help Reduce Their Use: 

Statement of Debra A. Draper:
Director, Health Care: 


Chairman Sanders, Ranking Member Paul, and Members of the Subcommittee: 

I am pleased to be here today to discuss strategies that health 
centers--facilities that provide primary care and other services to 
individuals in communities they serve regardless of ability to pay-- 
employ that may help reduce hospital emergency department use. 
Hospital emergency departments are a major component of the nation's 
health care safety net as they are open 24 hours a day, 7 days a week, 
and generally are required to medically screen all people regardless 
of ability to pay.[Footnote 1] From 1997 through 2007, U.S. emergency 
department per capita use increased 11 percent.[Footnote 2] In 2007, 
there were approximately 117 million visits to emergency departments; 
of these visits, approximately 8 percent were classified as nonurgent. 
[Footnote 3] The use of emergency departments, including use for 
nonurgent conditions, may increase as more people obtain health 
insurance coverage as the provisions of the Patient Protection and 
Affordable Care Act (PPACA) are implemented.[Footnote 4] 

Some nonurgent visits are for conditions that likely could be treated 
in other, more cost-effective settings, such as health centers. In 
2008, the average amount paid for a nonemergency visit to the 
emergency department was seven times more than that for a health 
center visit, according to national survey data.[Footnote 5] While 
there are many reasons individuals may go to the emergency department 
for conditions that could also be treated elsewhere, one reason may be 
the lack of timely access to care in other settings, possibly due to 
the shortage of primary care providers in some areas of the country. 

Like emergency departments, the nationwide network of health centers 
is an important component of the health care safety net for vulnerable 
populations, including those who may have difficulty obtaining access 
to health care because of financial limitations or other factors. 
Health centers, funded in part through grants from the Department of 
Health and Human Services' Health Resources and Services 
Administration (HRSA), provide comprehensive primary health care 
services--preventive, diagnostic, treatment, and emergency services, 
as well as referrals to specialty care--without regard to a patient's 
ability to pay. They also provide enabling services, such as case 
management and transportation, which help patients access care. In 
2009, more than 1,100 health center grantees operated more than 7,900 
delivery sites and served nearly 19 million people. With funding from 
PPACA--projected to be $11 billion over 5 years for the operation, 
expansion, and construction of health centers[Footnote 6]--health 
center capacity is expected to expand. 

My statement will highlight key findings from a report we are publicly 
releasing today that describes strategies that health centers have 
implemented that may help reduce the use of hospital emergency 
departments.[Footnote 7] For that report, we interviewed officials 
from 9 health centers, and conducted group interviews with officials 
from multiple health centers operating in three states, about 
strategies they have implemented that may help reduce emergency 
department use. We selected these health centers and states, based on 
our review of relevant literature and interviews with HRSA officials 
and experts, to provide geographic variation and to ensure that health 
centers serving rural and urban areas were represented. We also e-
mailed all state and regional primary care associations--private, 
nonprofit membership organizations of health centers and other 
providers--to identify specific health centers in their jurisdictions 
that had implemented strategies that may have reduced emergency 
department use.[Footnote 8] In addition, we collected information 
about health centers' strategies from the literature and our 
interviews with agency officials and experts. Our work was performed 
from November 2010 through April 2011 in accordance with generally 
accepted government auditing standards. 

In brief, our work found that health centers have implemented three 
types of strategies that may help reduce emergency department use. 
These strategies focus on (1) emergency department diversion, (2) care 
coordination, and (3) accessibility of services. For example, some 
health centers have collaborated with hospitals to divert emergency 
department patients by educating them on the appropriate use of the 
emergency department and the services offered at the health center. 
Additionally, by improving care coordination for their patients, 
health centers may help reduce emergency department visits by 
encouraging patients to first seek care at the health center and by 
reducing, if not preventing, disease-related emergencies from 
occurring. Finally, health centers employed various strategies to 
increase the accessibility of their services, such as offering evening 
and weekend hours and providing same-day or walk-in appointments--
which help position the health center as a convenient and viable 
alternative to the emergency department. Health center officials told 
us that they have limited data about the effectiveness of these 
strategies, but some officials provided anecdotal reports that the 
strategies have reduced emergency department use. These officials also 
described several challenges in implementing strategies that may help 
reduce emergency department use. For example, health center officials 
indicated that some services, such as those provided by case managers 
who may help coordinate care, are generally not reimbursed by third-
party payers. Additionally, some officials noted that it is difficult 
to change the behaviors of patients who frequent the emergency 
department and some noted challenges with recruiting the necessary 
health providers to serve their patients. 

Chairman Sanders, Ranking Member Paul, this concludes my prepared 
remarks. I would be pleased to respond to any questions you or other 
members of the subcommittee may have at this time. 

For questions about this statement, please contact Debra A. Draper at 
(202) 512-7114 or Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this statement. Individuals making key contributions to this 
testimony include Michelle B. Rosenberg, Assistant Director; Jennie F. 
Apter; Carolyn Feis Korman; and Katherine Mack. 

[End of section] 


[1] In order to participate in Medicare, hospitals are required to 
provide a medical screening examination to any person who comes to the 
emergency department and requests an examination or treatment for a 
medical condition, regardless of the individual's ability to pay. 
Social Security Act §§ 1866(a)(1)(I), 1867 (codified at 42 U.S.C. §§ 
1395cc(a)(1)(I), 1395dd). Medicare is the federal health program that 
covers seniors aged 65 and older, certain disabled persons, and 
individuals with end-stage renal disease. 

[2] In 1997, there were an estimated 35.6 emergency department visits 
per 100 people compared to 39.4 visits in 2007. See P. Nourjah, 
"National Hospital Ambulatory Medical Care Survey: 1997 Emergency 
Department Summary," Advance Data, no. 304 (1999), and R. Niska, F. 
Bhuiya, and J. Xu, "National Hospital Ambulatory Medical Care Survey: 
2007 Emergency Department Summary," National Health Statistics 
Reports, no. 26 (2010). 

[3] The National Center for Health Statistics developed time-based 
acuity levels based on a five-level emergency severity index 
recommended by the Emergency Nurses Association. The acuity levels 
describe the recommended time frame for being seen by a physician. The 
recommended time frames to be seen by a physician are less than 1 
minute for immediate patients, between 1 and 14 minutes for emergent 
patients, between 15 minutes and 1 hour for urgent patients, greater 
than 1 hour to 2 hours for semiurgent patients, and greater than 2 
hours to 24 hours for nonurgent patients. 

[4] We refer to the Patient Protection and Affordable Care Act, Pub. 
L. No. 111-148, 124 Stat. 119, as amended by the Health Care and 
Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat 
1029, as PPACA. According to estimates from the Congressional Budget 
Office (CBO), an additional 32 million individuals are projected to 
obtain health insurance coverage by 2019; CBO also estimates that 
gaining insurance increases an individual's demand for health care 
services by about 40 percent. See D. Elmendorf, Director, CBO, 
"Economic Effects of the March Health Legislation" (presentation at 
the Leonard D. Schaeffer Center for Health Policy and Economics, 
University of Southern California, Los Angeles, Calif., Oct. 22, 2010). 

[5] According to estimates from 2008 Medical Expenditures Panel Survey 
(MEPS), the average amount paid for a nonemergency visit to an 
emergency department was $792, while the average amount paid for a 
health center visit was $108. Similarly, the average charge for a 
nonemergency visit to an emergency department was 10 times higher than 
the charge for a visit to a health center--$2,101 compared to $203. 
MEPS is a set of large-scale surveys of families and individuals, 
their medical providers, and their employers across the United States. 

[6] Specifically, PPACA appropriated $9.5 billion for fiscal years 
2011 through 2015 to a new Community Health Centers Fund to enhance 
funding for HRSA's community health center program. It also provided 
$1.5 billion over that same time period for the construction and 
renovation of community health centers. Pub. L. No. 111-148, § 10503, 
124 Stat. 119, 1004 (2010); Pub. L. No. 111-152, § 2303, 124 Stat. 
1029, 1083. 

[7] GAO, Hospital Emergency Departments: Health Center Strategies That 
May Help Reduce Their Use, [hyperlink,] (Washington, D.C: Apr. 11, 

[8] We received responses from 21 of 52 regional and state primary 
care associations we contacted. 

[End of section] 

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