Hospital Emergency Departments
Health Center Strategies That May Help Reduce Their Use Gao ID: GAO-11-414R April 11, 2011Hospital 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.
GAO-11-414R, Hospital Emergency Departments: Health Center Strategies That May Help Reduce Their Use
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GAO-11-414R:
United States Government Accountability Office:
Washington, DC 20548:
April 11, 2011:
The Honorable Tom Harkin:
Chairman:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable Bernard Sander:
Chairman:
Subcommittee on Primary Health and Aging:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
Subject: Hospital Emergency Departments: Health Center Strategies That
May Help Reduce Their 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.
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 3]
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.[Footnote 4] 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.[Footnote 5]
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
[Footnote 6]--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.[Footnote 7]
Given the increased use of emergency departments, concern over
adequate access to primary care, and increased federal support for
health centers, you 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.
To conduct our work, we interviewed officials from 9 health centers
about strategies that they have implemented that may help reduce
emergency department use. We selected health centers to provide
geographic variation and to ensure that health centers serving rural
and urban areas were represented. We based our selection on our review
of relevant literature published in the past 5 years and interviews
with officials from HRSA and experts, specifically representatives
from the National Association of Community Health Centers and
individuals who have conducted research on health centers and
emergency department utilization. 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]
(Enclosure I provides selected characteristics of the individual
health centers interviewed.) To gain additional insights and
perspectives on the information obtained from the 9 individual health
centers, we also conducted group interviews with officials from
multiple health centers operating in three states.[Footnote 9] In our
interviews, we asked health center officials to describe the
strategies they have implemented that may help reduce the use of
emergency departments for conditions that might also be treated in
other care settings, such as health centers. We also asked health
center officials to describe key factors contributing to the
strategies' success and any challenges to implementation.
Additionally, we requested any data or evaluations the health centers
had on the effectiveness of each strategy implemented. We also
collected information about health centers' strategies from the
literature and our interviews with agency officials and experts.
We conducted this performance audit from November 2010 through April
2011 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Results in Brief:
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.
Background:
Emergency department visits are often made at night and on weekends by
patients with varying sources of payment and levels of severity. Not
all emergency department visits may be necessary; some visits may be
handled in less costly settings or even avoided altogether through
better management of chronic conditions. Lack of awareness of other
sources of care, lack of access to primary care and other providers,
and financial barriers can contribute to emergency department use,
including use for nonurgent conditions. Health centers, which are
required to serve patients regardless of ability to pay, are an
important safety net provider for financially or otherwise vulnerable
populations.
Emergency Department Use:
There were an estimated 116.8 million emergency department visits in
2007, according to the most recent publicly available report from
HHS's National Center for Health Statistics (NCHS).[Footnote 10] For a
majority of these visits (about 65 percent), patients arrived in the
emergency department on weekdays from 5 p.m. to 8 a.m., and on the
weekends.
Emergency department visits were made by patients with varying sources
of payment. Individuals with private insurance coverage represented
the largest percentage of emergency department visits followed by
those with health insurance coverage through Medicaid or the State
Children's Health Insurance Program (CHIP).[Footnote 11] (See table
1.) Research indicates that Medicaid patients have a
disproportionately higher share of emergency department use compared
to patients with other sources of payment.[Footnote 12]
Table 1: Emergency Department Visits by Source of Payment, 2007:
Source of payment: Private insurance;
Number of visits (in thousands): 45,580;
Percentage of visits: 39%.
Source of payment: Medicaid[A];
Number of visits (in thousands): 29,379;
Percentage of visits: 25%.
Source of payment: Medicare;
Number of visits (in thousands): 20,133;
Percentage of visits: 17%.
Source of payment: No insurance[B];
Number of visits (in thousands): 17,926;
Percentage of visits: 15%.
Source of payment: Unknown[C];
Number of visits (in thousands): 10,484;
Percentage of visits: 9%.
Source of payment: Other[D];
Number of visits (in thousands): 4,587;
Percentage of visits: 4%.
Source: GAO analysis of National Center for Health Statistics data.
Note: There were 116.8 million emergency department visits in 2007.
Because more than one expected source of payment may be reported per
visit, the total number of visits by source of payment exceeds 116.8
million and the sum of the percentage of visits by source of payment
exceeds 100 percent.
[A] Medicaid includes visits where the payment source was the State
Children's Health Insurance Program.
[B] The National Center for Health Statistics defines no insurance as
having only self-pay, no charge, or charity as payment sources.
[C] Unknown includes visits where the payment source was either
unknown or blank.
[D] Other includes visits where the payment source was workers'
compensation or other.
[End of table]
Patients present to the emergency department with illnesses or
injuries of varying severity, referred to as acuity level.[Footnote
13] Each acuity level corresponds to a recommended time frame for
being seen by a physician--for example, patients with "immediate"
conditions should be seen within 1 minute and patients with "emergent"
conditions should be seen within 1 to 14 minutes. In 2007, urgent
patients--patients who should be seen by a physician within 15 to 60
minutes--accounted for the highest percentage of visits to the
emergency department. Nonurgent patients--patients who should be seen
within 2 to 24 hours--accounted for 8 percent of visits. (See figure
1.)
Figure 1: Percentage of Emergency Department Visits by Acuity Levels,
2007:
[Refer to PDF for image: pie-chart]
Urgent: 39%;
Semiurgent: 21%;
No triage/unknown: 17%;
Emergent: 11%;
Nonurgent: 8%;
Immediate: 5%.
Source: GAO analysis of National Center for Health Statistics data.
Notes: 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. Because of rounding,
percentages do not add to 100.
[End of figure]
Studies have shown that some emergency department visits may have been
avoided through the use of appropriate and timely primary care and
preventive care.[Footnote 14] Additionally, better management of
chronic conditions, such as diabetes, asthma, and congestive heart
failure, could also reduce the need for emergency department visits.
There are a number of factors that contribute to the use of emergency
departments. Some patients may believe the emergency department
provides more convenient, comprehensive, and better quality care than
care provided in other settings. In addition, some patients may be
unaware of alternative sources of care available within their
community or may experience difficulty accessing primary or specialty
care. Specifically, patients may have difficulty finding providers
willing to accept new patients; patients with certain types of health
coverage, such as Medicaid; or patients who are uninsured. There may
also be difficulty finding providers with available and convenient
appointment times. For example, studies have found that emergency
department utilization is higher in areas with fewer primary care
providers, including areas with fewer health centers, and that growth
in emergency department visits among patients with mental health
conditions has coincided with reductions in the general availability
of mental health service providers.[Footnote 15] Finally, some
patients may perceive the emergency department to be an affordable
source of care, as emergency departments generally provide medical
screenings to patients regardless of their ability to pay.
HRSA's Health Center Program:
To increase access to primary care services for the medically
underserved, HRSA provides grants to health centers nationwide under
Section 330 of the Public Health Service Act.[Footnote 16] Health
centers participating in HRSA's Health Center Program are private,
nonprofit community-based organizations or, less commonly, public
organizations such as public health department clinics. Health centers
are required to have a governing board, the majority of which must be
patients of the health center.[Footnote 17]
Health centers also are required to provide comprehensive primary
health care services, including preventive, diagnostic, treatment, and
emergency services. Moreover, they are required to provide referrals
to specialty care and substance abuse and mental health services.
Health centers may use program funds to provide such services
themselves or to reimburse other providers.[Footnote 18] A
distinguishing feature of health centers is that they are required to
provide enabling services that facilitate access to health care, such
as case management, translation, and transportation. Additionally,
HRSA requires health centers to provide services at times and
locations that ensure accessibility and meet the needs of the
population to be served, and to provide professional coverage for
medical emergencies during hours when the center is closed. Health
center services, which may be offered at one or more delivery sites,
must be available to all individuals in the center's service area with
fees adjusted based on an individual's ability to pay. Uninsured
individuals are charged for services based on a sliding fee schedule
that takes into account their income level.
Health centers primarily serve low-income populations in medically
underserved areas. According to HRSA data, in 2009, the majority of
health center patients whose family income was known had income at or
below the federal poverty level.[Footnote 19] In addition, 38 percent
of health center patients were uninsured and 25 percent spoke a
primary language other than English, the latter of which could
indicate a potential barrier in accessing primary care at other
settings that do not offer translation services. In 2009, half of all
HRSA-funded health centers were located in rural areas.
Research has shown that the annual health care expenditures for
patients receiving care at health centers were lower than those for
other patients. For example, one study showed that average health care
expenditures for a person who received care at a health center were
$3,500 compared to $4,594 for a similar person who did not receive
care at a health center.[Footnote 20]
Health Centers Have Implemented Three Types of Strategies That May
Help Reduce Emergency Department Use:
Health centers have implemented three types of strategies that may
help reduce emergency department use, namely strategies for (1)
emergency department diversion, (2) care coordination, and (3)
increasing the accessibility of services, according to our interviews
with experts and health center officials. Our review of the literature
also identified similar types of strategies.
* Emergency Department Diversion. Health centers' emergency department
diversion strategies are intended to encourage certain emergency
department patients to use a health center as an alternative to
emergency department care. Such diversion strategies, which generally
are implemented in collaboration with a hospital, focus on educating
emergency department patients on the appropriate use of the emergency
department; informing them about the services offered at the health
center; and arranging appointments at, or referrals to, the
participating health center. Emergency department diversion strategies
may be targeted at patients whose visits are nonurgent, who lack a
regular source of care, who are uninsured or who have Medicaid, or who
are frequent users of the emergency department.[Footnote 21] According
to the health center officials we interviewed, their diversion
strategies most commonly focused on preventing future visits to the
emergency department, typically involving health center or hospital
officials interacting with patients after those patients were seen by
emergency department physicians. However, a Colorado health center's
program refers emergency department patients triaged with less acute
conditions to walk-in appointments for treatment at the health
center's site, located less than a mile from the hospital. (See table
2 for other examples of emergency department diversion strategies
implemented by selected health centers.) According to health center
officials, for an emergency department diversion strategy to be
successful, there must be good communication between the health center
and the hospital and buy-in from the hospital's administration and
emergency department staff. Such buy-in is essential because,
according to experts and health center officials we interviewed,
hospitals and emergency department physicians may face financial
disincentives to divert patients.[Footnote 22]
Table 2: Examples of Emergency Department Diversion Strategies Used by
Selected Health Centers:
Health center (state): Baltimore Medical System (Maryland);
Description of emergency department diversion strategy: The health
center works with a local hospital to link eligible patients--
specifically, Medicaid and uninsured patients with two or more
emergency department visits in the previous year--to a primary care
provider at the health center;
* The health center stations community health workers at the emergency
department from 8 a.m. to 11 p.m. weekdays and some weekend hours;
* Community health workers meet with eligible patients after triage by
emergency department staff to discuss the benefits and services
available at the health center;
* Community health workers schedule follow-up appointments for
patients who would like to receive care at the health center;
* The health center uses charitable contributions from corporations to
pay for the patient's first health center visit and first
prescriptions;
* At their first health center appointments, patients are connected to
primary care providers who, in coordination with case managers,
oversee the patients' future needs.
Health center (state): Brockton Neighborhood Health Center
(Massachusetts);
Description of emergency department diversion strategy: The health
center works with two local hospitals to develop treatment plans for
health center patients identified as having 12 or more emergency
department visits within a year;
* Hospital staff notify the health center if an identified patient
presents at the emergency department;
* Health center and hospital staff work together to develop a
discharge plan for the patient, including scheduling an appointment
for the patient at the health center, if necessary;
* During monthly meetings, health center and hospital staff discuss
why targeted patients use the emergency department and how care plans
can be improved to prevent future use.
Health center (state): LifeLong Medical Care (California);
Description of emergency department diversion strategy: As a
participant in a countywide initiative, the health center collaborates
with other providers in the community to provide linkages to services
and manage care for frequent emergency department users, defined as
patients who had 10 or more visits in 12 months, or 4 or more visits
in each of 2 consecutive years;
* Health center case managers conduct outreach at three hospital
emergency departments to identify patients in the target population
and offer to connect them to a comprehensive set of health and social
services;
* The case managers follow up with patients after they leave the
emergency department to help ensure that the patients receive needed
services;
the case managers provide incentives, such as food and transportation,
to encourage the patients to come to the health center for medical
services.
Source: GAO analysis of information obtained through communications
with, and documents provided by, officials from selected health
centers.
[End of table]
* Care Coordination. By coordinating the care of their patients,
health centers may help reduce emergency department use by working to
ensure that patients first seek care at health centers instead of
emergency departments and by focusing on the prevention of disease-
related emergencies. Care coordination may include establishing a plan
of care that is managed jointly by the patient and the health care
team, anticipating routine needs, and actively tracking progress
toward patient care plan goals. Health center officials we spoke with
described two types of care coordination strategies--the medical home
model and chronic care management. The medical home model uses a care
team led by a physician who provides continuous and comprehensive care
to patients with the aim of maximizing health outcomes.[Footnote 23]
Chronic care management focuses on monitoring and managing chronic
conditions, such as diabetes, asthma, and heart disease, through
preventative care, screening, and patient education on healthy
lifestyles. (See table 3 for examples of care coordination strategies
implemented by selected health centers.) Some health center officials
we interviewed noted the importance of including mental health
services and patient education as key components to the success of
care coordination. They also noted that health centers' electronic
medical records, especially when compatible with hospital systems, are
helpful in coordinating care but that acquiring the technology can be
expensive.
Table 3: Examples of Care Coordination Strategies Used by Selected
Health Centers:
Health center (state): Health West (Idaho);
Description of care coordination strategy: The health center
coordinates care for patients with chronic diseases, such as diabetes
and cardiovascular disease, by proactively scheduling appointments for
care. The health center's physicians indicate when patients need to
come in for their next visits. The information is recorded in the
health center's electronic medical records and a report is generated
each week identifying patients due for appointments. Health center
staff then contact each patient to schedule an appointment.
Health center (state): Lincoln Community Health Center (North
Carolina);
Description of care coordination strategy: The health center has
education and support groups for patients with certain chronic
conditions, including diabetes and hypertension. The groups include
patient education, such as food and nutrition instruction provided by
a dietician; social support, such as a walking club to encourage
exercise; and medication management and guidance on prescription
compliance. In addition, health center staff work to coordinate care
for all patients by, among other things, following up on missed
appointments and scheduling appointments to coincide with patients'
needs for prescription refills.
Health center (state): Northern Counties Health Care (Vermont);
Description of care coordination strategy: Through its medical home
model, the health center's primary care physicians are responsible for
coordinating all levels of patient care, including referring patients
to specialty care, and connecting patients to community services. The
primary care physicians work with a team of providers, including
behavioral health therapists and chronic care coordinators, to ensure
that patients receive necessary care. For example, patients may be
referred to the behavioral health therapist for smoking cessation or
assistance managing drug and alcohol dependence.
Source: GAO analysis of information obtained through communications
with, and documents provided by, officials from selected health
centers.
[End of table]
* Accessible Services. Health centers employ various strategies to
make their services accessible and to raise community awareness of the
services they offer, which can help position the health center as a
convenient and viable alternative to the emergency department. Such
strategies include expanding health center hours to include evenings
and weekends; providing same-day or walk-in appointments; providing
transportation to health center locations; and locating health center
sites in convenient places, such as in or near hospitals, schools, and
homeless shelters. Health centers also use strategies to provide care
to patients outside of the health center, such as through
telemedicine, home visits, and mobile clinics, and may use translators
to reduce linguistic and cultural barriers to care. In addition,
health centers may engage in outreach activities to increase awareness
of their services. For example, a health center in Wisconsin works
with individuals at local community agencies that serve the poor and
uninsured, including public health workers, clergy, and social
workers, to encourage them to refer individuals to the health center
for services. (See table 4 for other examples of strategies health
centers have implemented to increase the accessibility of their
services.)
Table 4: Examples of Strategies Used by Selected Health Centers to
Increase the Accessibility of Their Services:
Health center (state): Access Community Health Network (Illinois);
Examples of strategies to increase accessibility of services: The
health center has several strategies to help ensure that its services
are accessible and that the community is aware of the services
offered. For example:
* The health center has 58 sites, including sites located in schools
and a few sites established on hospital campuses;
* The health center's sites accept walk-in patients and most have
extended hours; most sites offer Saturday hours, many sites are open
until 8 p.m. a few nights per week, and 1 site is open until 10 p.m.
Monday through Friday;
* The health center provides phone answering service coverage through
which patients can talk to physicians when necessary, even after hours
when health center sites are closed;
* The health center provides sign language interpretation and has
bilingual and multicultural staff members, who reflect the population
of the communities served;
* The health center increases awareness of its services through
outreach to social service agencies, participation in health fairs,
and co-branding signs and other informational materials with a local
hospital.
Health center (state): Community Health Centers (Oklahoma);
Examples of strategies to increase accessibility of services: To
increase access to its services, the health center;
* has evening hours, until 7 p.m., 3 days a week at one site and 1 day
a week at a second site;
* schedules appointments only 3 days in advance at one of its sites to
reduce wait times for an appointment and maximize appointment times;
and;
* provides transportation to the health center for homeless
individuals by distributing bus tokens at one homeless shelter and
providing van services from several other shelters.
Health center (state): United Neighborhood Health Services (Tennessee);
Examples of strategies to increase accessibility of services: To
increase access to its services, the health center;
* operates 16 sites, including a site targeted to homeless patients, 5
school-based clinics, and sites near local hospitals and also operates
2 mobile clinics;
* offers Saturday hours at 3 sites and evening hours (until 10 p.m.)
at 1 site 5 days per week; and;
* accepts walk-in patients at all health center sites any day the site
is open.
Source: GAO analysis of information obtained through communications
with, and documents provided by, officials from selected health
centers.
[End of table]
Health center officials told us that they had limited data about their
strategies' effectiveness at reducing emergency department use and
indicated that because health centers often implemented multiple
strategies, evaluating the effectiveness of any one would be
challenging. Officials from one health center we spoke with did have
an evaluation of the countywide emergency department diversion program
it participated in, which found that emergency department visits for
participating patients decreased by 63 percent 1 year after patients
enrolled in the program. Other health center officials provided
anecdotal reports of the impact of various strategies they
implemented. For example, health center officials from Pennsylvania
reported that offering extended hours did help reduce the use of the
emergency department. Additionally, officials from a health center
that provides care coordination indicated that they have seen an
increase in routine visits, which they believe is helping to prevent
some emergency department visits.
Health center officials described several challenges in implementing
strategies that may help reduce emergency department use.
Specifically, officials noted that some services, such as those
provided by case managers, are generally not reimbursed by third-party
payers, but instead must be funded in total by the center.[Footnote
24] Another challenge, according to health center officials, is that
health centers do not benefit from any cost savings resulting from
reductions in emergency department visits. Additionally, health center
officials noted that it is difficult to change the care-seeking
behaviors of certain patients who frequently use the emergency
department, including those who are homeless or have substance abuse
and mental health problems. Finally, some health center officials
noted challenges with recruiting the necessary health providers to
serve their patients. Given that the demand for services may increase
as more individuals gain health insurance coverage as a result of
PPACA, several health center officials we spoke with reported that
they have applied for, or expect to apply for, additional health
center funding from HRSA to expand services (such as by hiring new
providers), open new sites, or renovate existing sites.
Agency Comments:
We provided a draft of this report to HHS for review and comment. HHS
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this report are listed in enclosure II.
Signed by:
Debra A. Draper:
Director, Health Care:
Enclosures - 2:
[End of section]
Enclosure I:
Table: Characteristics of Individual Health Centers Interviewed, 2010:
Health center (state): Access Community Health Network (Illinois);
Number of sites: 58;
Latest weekday closing time[A]: 10 p.m.;
Saturday hours[A]: Yes;
Number of patient visits in 2009: 799,065;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 32;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 55;
Percentage of patients by coverage status in 2009[B]: Medicare: 4;
Percentage of patients by coverage status in 2009[B]: Private: 9.
Health center (state): Baltimore Medical System (Maryland);
Number of sites: 12;
Latest weekday closing time[A]: 7 p.m.;
Saturday hours[A]: Yes;
Number of patient visits in 2009: 168,552;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 20;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 48;
Percentage of patients by coverage status in 2009[B]: Medicare: 11;
Percentage of patients by coverage status in 2009[B]: Private: 21.
Health center (state): Brockton Neighborhood Health Center
(Massachusetts);
Number of sites: 2;
Latest weekday closing time[A]: 8 p.m.;
Saturday hours[A]: Yes;
Number of patient visits in 2009: 100,586;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 31;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 60;
Percentage of patients by coverage status in 2009[B]: Medicare: 5;
Percentage of patients by coverage status in 2009[B]: Private: 4.
Health center (state): Community Health Centers (Oklahoma);
Number of sites: 4;
Latest weekday closing time[A]: 7 p.m.;
Saturday hours[A]: No;
Number of patient visits in 2009: 49,768;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 73;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 18;
Percentage of patients by coverage status in 2009[B]: Medicare: 4;
Percentage of patients by coverage status in 2009[B]: Private: 5.
Health center (state): Health West (Idaho);
Number of sites: 6;
Latest weekday closing time[A]: 6:30 p.m.;
Saturday hours[A]: No;
Number of patient visits in 2009: 23,000;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 47;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 17;
Percentage of patients by coverage status in 2009[B]: Medicare: 12;
Percentage of patients by coverage status in 2009[B]: Private: 24.
Health center (state): LifeLong Medical Care (California);
Number of sites: 9;
Latest weekday closing time[A]: 9 p.m.;
Saturday hours[A]: Yes;
Number of patient visits in 2009: 170,098;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 28;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 35;
Percentage of patients by coverage status in 2009[B]: Medicare: 26;
Percentage of patients by coverage status in 2009[B]: Private: 11.
Health center (state): Lincoln Community Health Center (North
Carolina);
Number of sites: 7;
Latest weekday closing time[A]: 8 p.m.;
Saturday hours[A]: Yes;
Number of patient visits in 2009: 139,694;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 80;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 12;
Percentage of patients by coverage status in 2009[B]: Medicare: 6;
Percentage of patients by coverage status in 2009[B]: Private: 3.
Health center (state): Northern Counties Health Care (Vermont);
Number of sites: 8[E];
Latest weekday closing time[A]: 7 p.m.;
Saturday hours[A]: No;
Number of patient visits in 2009: 76,250;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 8;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 26;
Percentage of patients by coverage status in 2009[B]: Medicare: 22;
Percentage of patients by coverage status in 2009[B]: Private: 44.
Health center (state): United Neighborhood Health Services (Tennessee);
Number of sites: 16;
Latest weekday closing time[A]: 10 p.m.;
Saturday hours[A]: Yes;
Number of patient visits in 2009: 89,454;
Percentage of patients by coverage status in 2009[B]: Uninsured[C]: 51;
Percentage of patients by coverage status in 2009[B]: Medicaid[D]: 34;
Percentage of patients by coverage status in 2009[B]: Medicare: 4;
Percentage of patients by coverage status in 2009[B]: Private: 11.
Source: GAO analysis of information obtained through communications
with, and documents provided by, officials from selected health
centers.
[A] Evening and Saturday hours may not be available at all of a health
center's sites and evening hours may not be available all weeknights.
[B] The totals may not add up to 100 percent because of rounding.
[C] Uninsured also may include self-pay patients, those who paid out
of pocket.
[D] Medicaid may also include people enrolled in the State Children's
Health Insurance Program.
[E] The health center also offers a home health and hospice program,
which provides services 24 hours a day, 7 days a week.
[End of table]
[End of Enclosure I]
Enclosure II: GAO Contact and Staff Acknowledgments:
GAO Contact:
Debra A. Draper, (202) 512-7114 or draperd@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, key contributors to this
report were Michelle B. Rosenberg, Assistant Director; Jennie F.
Apter; Matthew Gever; Carolyn Feis Korman; Katherine Mack; Margaret J.
Weber; and Jennifer Whitworth.
[End of Enclosure II]
Footnotes:
[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] For purposes of this report, 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).
[4] According to estimates from the 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.
[5] In 2009, we reported that patients' lack of access to primary care
services was one factor that may contribute to emergency department
crowding. The report, which provided a follow-up to a 2003 report on
emergency department crowding, also noted that crowding continued to
occur in hospital emergency departments and that some indicators of
emergency department crowding--such as the amount of time patients
must wait to see a physician--suggested that the situation may have
worsened. See GAO, Hospital Emergency Departments: Crowding Continues
to Occur, and Some Patients Wait Longer than Recommended Time Frames,
[hyperlink, http://www.gao.gov/products/GAO-09-347] (Washington, D.C.:
Apr. 30, 2009), and Hospital Emergency Departments: Crowded Conditions
Vary among Hospitals and Communities, [hyperlink,
http://www.gao.gov/products/GAO-03-460] (Washington, D.C.: Mar. 14,
2003).
[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] National Association of Community Health Centers, Expanding Health
Centers Under Health Care Reform: Doubling Patient Capacity and
Bringing Down Costs (Bethesda, Md., June 2010).
[8] We received responses from 21 of 52 regional and state primary
care associations we contacted.
[9] Specifically, we conducted group interviews with officials from 6
health centers in Colorado, 13 health centers in Pennsylvania, and 9
health centers in Wisconsin. Similar to our individual health center
selection, these states were selected to provide geographic variation
and to ensure that health centers serving rural and urban areas were
represented.
[10] NCHS is an agency within HHS's Centers for Disease Control and
Prevention that compiles statistical information to guide actions and
policies to improve health. Annually, NCHS collects data on U.S.
hospital emergency department utilization using a nationally
representative survey, the National Hospital Ambulatory Medical Care
Survey.
[11] Medicaid is a joint federal-state program that finances health
care for certain low-income adults and children. CHIP is a joint
federal-state program that finances health care coverage for children
in families with incomes that, while low, are above Medicaid
eligibility requirements.
[12] See, for example, Committee for the Future of Emergency Care in
the United States Health System, Hospital-Based Emergency Care: At the
Breaking Point (Washington, D.C.: National Academies Press, 2007).
[13] NCHS developed time-based acuity levels based on a five-level
emergency severity index recommended by the Emergency Nurses
Association.
[14] For a review of literature on emergency department utilization,
including utilization of the emergency departments for potentially
preventable conditions, see D. DeLia and J. Cantor, Emergency
Department Utilization and Capacity, Research Synthesis Report No. 17
(Princeton, N.J.: The Robert Wood Johnson Foundation, The Synthesis
Project, July 2009).
[15] See, for example, P. Cunningham, "What Accounts for Differences
in the Use of Hospital Emergency Departments Across U.S. Communities?"
Health Affairs, vol. 25, no. 5 (2006), and P. Cunningham, K. McKenzie,
and E. Taylor, "The Struggle to Provide Community-Based Care to Low-
Income People with Serious Mental Illness," Health Affairs, vol. 25,
no. 3 (2006).
[16] 42 U.S.C. § 254b.
[17] 42 U.S.C. § 254b(k)(3)(H). Under certain circumstances, the
requirement for a governing board may be waived, such as for centers
funded to serve only one or more of the following: homeless, migrant,
or public-housing populations.
[18] Health centers funded to serve homeless individuals are required
to provide substance abuse services.
[19] Family income was known for approximately 75 percent of health
center patients.
[20] The study, which compared 2006 annual medical expenditures of
people who received care at health centers and those who had not, made
adjustments for an array of factors, including age, gender, income,
insurance coverage, and health status. See L. Ku, P. Richard, A. Dor,
E. Tan, P. Shin, and S. Rosenbaum, "Strengthening Primary Care to Bend
the Cost Curve: The Expansion of Community Health Centers Through
Health Reform," Geiger Gibson/RCHN Community Health Foundation
Research Collaboration, Policy Research Brief No. 19. (Washington,
D.C.: The George Washington University School of Public Health and
Health Services, June 30, 2010).
[21] Health center officials we interviewed provided varying
definitions of frequent users, ranging from individuals with 2 or more
visits per year to individuals with 12 or more visits per year.
[22] Officials from one health center stated that some emergency
department physicians are paid based on volume and, therefore, may be
less willing to divert patients. Additionally, experts and health
center officials indicated that hospitals may have an incentive to
only divert uninsured patients, who may provide no payment to the
hospital or health center.
[23] Under the medical home model, the care team is responsible for
providing for all of a patient's health care needs or appropriately
arranging for care with other qualified professionals. This includes
the provision of preventive services and treatment of acute and
chronic illness.
[24] We previously reported that care coordination services are
generally not covered by health insurance. See GAO, Health Care
Delivery: Features of Integrated Systems Support Patient Care
Strategies and Access to Care, but Systems Face Challenges,
[hyperlink, http://www.gao.gov/products/GAO-11-49] (Washington, D.C.:
Nov. 16, 2010).
[End of section]
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