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Emergency Rooms: Not for Everybody?

Some NJ hospitals are marketing their emergency rooms to insured patients, while the state struggles to reduce ER visits by Medicaid recipients.

Common wisdom in the healthcare industry: emergency room visits represent the biggest cost to hospitals. Then why is Robert Wood Johnson University Hospital in Hamilton mounting a marketing campaign to pull patients into its ER? Its recently announced 15/30 pledge promises a medical evaluation within 15 minutes of arrival and an exam within 30.

Robert Wood Johnson is hardly alone. Hospitals across the state are expanding their emergency departments and striving to cut waiting times to compete for patients.

Meanwhile, the state is struggling to reduce ER use by Medicaid recipients.

Suzanne Ianni , CEO of the Hospital Alliance of New Jersey, whose members include “safety net” hospitals in cities with large charity care and Medicaid caseloads, helps reconcile these two trends. She said hospitals are advertising their low ER waiting times in order to attract patients with commercial health insurance, which pays better rates to the hospital than Medicaid.

“It’s not going to help [the hospital] if they get more charity care and Medicaid patients through the door,” she said.

Skip Cimino, CEO of Robert Wood Johnson University Hospital also believes that these trends are not diametrically opposed.

“The state is trying to do a good thing as it relates to ED” use by Medicaid patients, Cimino said. He noted he has worked with the state Department of Human Services (DHS) to reduce trips to the ER for less acute conditions by improving primary care for Medicaid members. But Cimino said a patient who already has a family doctor “will call their doctor in the middle of the night, and the doctor will say, ‘go to the ER.’ It's our responsibility to take care of them.”

Emergency room use is on the rise nationwide, from 123.7 million visits in 2008 to 136 million in 2009, the most recent figures available from the Centers for Disease Control and Prevention. Cimino did not have stats for New Jersey, but he estimated that ED visits have been flat in recent years, and that hospitals that attract more visits are gaining market share from other hospitals.

Cimino said it took several years to revamp the Robert Wood Johnson ED to make the 15/30 pledge feasible. Dr. Eileen Singer, chair of the department of emergency medicine, said changes included putting teams with a doctor, two nurses and a technician in zones “where they just treat a certain amount of patients and they aren’t walking back forth.”

Nationwide, more than half of hospital admissions come in through the ER, but that figure is 70 percent for RWJ, according to Cimino. “So our focus on emergency medicine impacts the whole hospital.”

The state addressed what it sees as excess ED utilization in the waiver it submitted to the federal government, seeking to reform its Medicaid program. The waiver states that DHS will appoint a task force to recommend by January 1 how to reduce non-emergency use of the ER, which could include requiring co-payments from Medicaid members and creating “ER diversion programs.” According to DHS, 62 percent of Medicaid visits to the ER are for non-emergency issues.

Ward Sanders, president of the New Jersey Association of Health Plans, the trade group for health insurers, is opposed to emergency room care for non-emergencies. “Quality and cost suffer if patients receive non-acute care in the ER,” he said. “Quality is affected because a primary care physician is much more likely to know a patient’s medical history and baseline medical status, which can be used as part of decision-making on how to proceed, and is better equipped to manage follow-up care."

Sanders continued, "A hospital ER doctor may not have access to medical records or have a relationship with the patient. Cost is affected because the cost of care for something like the common cold in an ER is significantly higher” than in a primary care physician’s office. He added that the cost differential extends to NJ FamilyCare, which is the state’s expansion of Medicaid. Sanders said the higher cost “affects taxpayers, as the state is the ultimate payer for NJ FamilyCare and the State Health Benefits Program, and other payers.”

Sanders said it’s difficult to solve what he sees as a problem of excess ED use, “but it certainly is made worse by hospitals actually advertising for low-acuity care. We would like to see the practice of advertising for low-acuity care restricted or banned.”

Dr. Michael Gerardi is on the board of the American College of Emergency Physicians and director of pediatric emergency medicine at Morristown Medical Center. He said ED visits are on the rise “because people realize the ED is the best place to get an answer as quickly as possible for whatever ails them. We have a lot of tools available to us: you can get a CAT scan or an ultrasound and a total work up in six to eight hours, instead of several days.”

He said Morristown is in the midst of expanding its ED, which now sees about 85,000 patients a year, a number he expects will rise to 100,000 in three years. He said someone who is seriously ill should not drive longer to get to a hospital with a shorter wait time -- since all ED’s triage patients to make sure the sickest are seen immediately.

Gerardi estimated that 40 percent of Morristown’s admissions come through the ED “so a healthy thriving ED is key to a hospital’s success. You want the doctors in the community to be comfortable referring people to your hospital."

He said there is a shortage of doctors to provide primary care to Medicaid patients in part because Medicaid reimbursement rates are so low. He said he receives about $28 to treat a Medicaid patient in the ED.

In September, Hackensack University Medical Center began posting wait times online for its satellite emergency room at Pascack Valley “to better communicate with our patients and their families. So far the reaction has been great. Patients and families know what to expect, even during the busiest times of the day,” said Darlene Cox, administrative director, Emergency Services.

“Wait times are calculated based on the average of the two-hour period prior to the posted estimate. Times are calculated from check-in to when the patient is seen by a physician," said Benjamin Bordonaro, acting chief information officer and chief technology officer.

Dr. David Istvan, chief of the ED at Englewood Hospital and Medical Center, said in 2009 the ED was renovated for $30 million and now has 40 private rooms where family members can stay with the patient. He said it’s essential for a hospital to have a first-rate ED, because the community sees the ED as the center of the hospital. And with patient admissions expected to decline in the future, and more complex procedures done on an outpatient basis, the ED will increasingly be the public face of the hospital.

“In the minds of the public, the hospital is an ED with lots of different departments to support it.” He said patients chose to go to the ED instead of the doctor’s office for various reasons, and it’s difficult to second guess that decision.

“Sometimes they have a good reason for going to the ED and sometimes not. They may not have a doctor, or the doctor is not available, and they make the decision themselves,” he said.

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