What the role of the modern ED should be

B A Fisher
Cost & Quality Quarterly Journal: CQ 1999, 5 (1): 28-37; quiz 38
Managed care organizations (MCOs) have recently focused on the high cost per patient visit in the Emergency Department (ED). MCOs emphasize preventing low acuity patients access to the ED, believing that billions of healthcare dollars will be saved. However, a review of emergency department studies suggests a different outcome. Combined with new ED service lines, perhaps another, rather paradoxical approach to managing healthcare costs in the ED is more patient focused and more cost-effective long-term. This approach is more comprehensive and offers more services, not less. The ED is an important community resource and entry port to healthcare. It is the only place open 24-hours per day, 7 days per week with no appointment necessary, and all lab and radiology services available. The very claim that it is "overutilized" is an indication of its success. In large volume EDs, certain patient populations may be more specifically served with pediatric emergency, industrial medicine, and fast track physicians. Special facilities for chest pain patients or observation can treat patients more quickly, keep them out of hospital beds, thus lowering costs. In smaller hospitals, the well rounded ED physician can treat patients of all acuities. In the most rural communities the ED can become the local 24-hour clinic with short-term stay beds. EDs are fixed costs to hospitals. Extracting low acuity patients from the ED will raise costs for emergency patients and leave the facility underutilized. By appropriately raising prices for emergencies and decreasing low acuity patient charges to reflect marginal expense, the ED becomes a cost friendly environment for the low acuity patient.

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