Emergency Department Visits: Health Reform's Canary or Phoenix

BACKGROUND: Since the passage in 1986 of the Emergency Medical Treatment and Active Labor Act (EMTALA) the emergency department (ED) has become the “safety net for the safety net.” Visits to hospital emergency departments grew 26% between 1993 and 2003, reaching 119 million in 2006. To better understand who is using the ED and how, considerable research attention has been directed at ED use by payer, specifically Medicaid and self-pay, and for ambulatory care sensitive conditions (ACSCs), a measure of the adequacy of a community's primary care capacity. Federally qualified health centers (FQHC) are safety net providers, serving qualified underserved populations regardless of ability to pay. The growth in the number of FQHCs, spurred by increasing appropriation levels during the G.W. Bush Administration, led to studies of FQHC impact on ED use overall and for ACSCs specifically. Fewer studies have focused on rural EDs and the impact of an FQHC. The availability of ED data for all Florida hospitals for 2005 and 2006 provided an opportunity to assess the impact of FQHCs on rates of total ED visits, visits for ACSC and a subset of the most prevalent ACSCs, specifically asthma, diabetes, and COPD. METHODOLOGY: ED data was obtained from the Florida Agency for Health Care Administration. Classification of counties into rural and urban is based on the 2003 Rural-Urban Continuum Codes. Additional data elements from the Area Resource File and the Census were merged with the ED data. Cross-tabulations and graphical analysis were used to examine certain features of the data. Negative-Binomial (NB) specification was employed for modeling. All statistical analyses were conducted using SAS version 9.1. RESULTS: Total ED visits grew 2.8% between 2005 and 2006. Visits for ACSC grew by .05%. The average number of ED visits in rural areas is slightly higher than in urban areas for total visits and for each of the specified ACSC. Traditional Medicare and Medicaid pay for a greater percentage of ED visits for rural versus urban. The presence of an FHQC has a statistically significant negative effect on ED visits. In a rural county, the presence of an FQHC is related to marginally fewer ED visits for asthma and diabetes, and slightly more for COPD. CONCLUSIONS: The presence of an FQHC is related to fewer ED visits for ACSC overall, however, recent concerns related to adequacy of primary care workforce may limit the potential benefits.