The number of emergency departments (EDs) in non-rural America has fallen by 27%, from 2,446 in 1990 to 1,779 in 2009, while the number of ED visits over the last decade has risen, researchers from the University of California reported in JAMA (Journal of the American Medical Association). Emergency Departments have to by law evaluate and treat anyone in need of emergency care, no matter what their financial or insurance situation is.
The main characteristics linked to this fall in ED numbers are:
- For-profit ownership
- Location in a competitive market
- Low profit margin
- Low-safety net status
As background information, the authors wrote:
“As the only place in the U.S. health care system that serves all patients, emergency departments (EDs) are the ‘safety net of the safety net.’ Federal law requires hospital EDs to evaluate and treat all patients in need of emergency care regardless of ability to pay. Between 1998 and 2008, the number of hospital-based EDs in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures.”
Renee Y. Hsia, M.D., M.Sc. and team set out to determine what factors might be linked to ED closures. They gathered data on EDs and hospital organizations from 1990 through 2009 from the American Hospital Association Annual Surveys. They also analyzed data from Medicare hospital cost reports.
Below are some highlighted details of their findings (1990 to 2009):
- In 1990 there were 2,446 EDs, compared to 1,779 in 2009. A drop of 27%.
- An average of 89 EDs closed each year during the two decades – or 1.7 each week.
- From 1900 to 2007 26% of EDs that closed were at for-profit hospitals, while 16% of the EDs that stayed open were in for-profit hospitals.
- EDs at smaller facilities had a higher probability of closing down.
- Twice as many hospitals in the lowest quartile of the profit margin distribution closed their EDs compared to other hospitals.
- A significant proportion of closing EDs were in areas with high minority populations, more poverty, and at least 15% of people without insurance.
- 34% of closures occurred in areas with another ED nearby.
The researchers found that three hospital-specific characteristics were linked to a higher chance of their ED closing down, including for-profit status, safety-net status, and low profit margin (lowest quartile). After all factors were taken into account, they established that EDs in high poverty areas had a significantly higher likelihood of closing down, compared to those in other communities.
Nearby competition was also another factor. An ED had a higher risk of closing down if it was located within a 15-mile radius of another one.
The authors wrote:
“Our findings underscore that market-based approaches to health care do not ensure that care will be equitably distributed. In fact, the opposite may be true. As long as tens of millions of Americans are uninsured, and tens of millions more pay well below their cost of care, the push for ‘results-driven competition’ will not correct system-level disparities that markets cannot – and should not – be expected to resolve.
“It is critical to determine whether and how to engage society in decisions to maintain or close EDs and other safety-net services.”
Renee Y. Hsia, MD, MSc; Arthur L. Kellermann, MD, MPH; Yu-Chu Shen, PhD
JAMA. 2011;305(19):1978-1985. doi: 10.1001/jama.2011.620
Written by Christian Nordqvist