Hospital Emergency Departments:
Health Center Strategies That May Help Reduce Their Use
GAO-11-414R, Apr 11, 2011
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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. From 1997 through 2007, U.S. emergency department per capita use increased 11 percent. In 2007, there were approximately 117 million visits to emergency departments; of these visits, approximately 8 percent were classified as nonurgent. 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. Some nonurgent visits are for conditions that likely could be treated in other, more cost-effective settings, such as health centers--facilities that provide primary care and other services to individuals in communities they serve regardless of ability to pay. Care provided in an emergency department may be substantially more costly than care provided in a health center. 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. 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 seen in some areas of the country. Health centers may serve as a less costly alternative to emergency departments, particularly for individuals with nonurgent conditions. 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, which are funded in part through grants from the Department of Health and Human Services' (HHS) 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 increased funding from PPACA--projected to be $11 billion over 5 years for the operation, expansion, and construction of health centers--health center capacity is expected to significantly expand, with the National Association of Community Health Centers estimating that health centers could more than double their capacity to 40 million patients by 2015. Given the increased use of emergency departments, concern over adequate access to primary care, and increased federal support for health centers, Congress requested that we examine how health centers may help reduce the use of emergency departments. In this report, we describe strategies that health centers have implemented that may help reduce the use of hospital emergency departments.
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. Health center officials described several challenges in implementing strategies that may help reduce emergency department use, such as the difficulty in changing the behaviors of patients who frequent the emergency department. HHS provided a technical comment on a draft of this report, which we incorporated.