Exploring a New Mechanism Increasing Emergency Department Visits Katrina Hull University at Albany

Introduction 440 420

ED Vistis per 1000

400 380

Increase Outside Model Boundary

360

Physicians Redirecting Patients

340 320 300 1990

1995

2000 Model

Historic

2005

2010

2015

No Change

Historical Data from Avalere Health analysis of American Hospital Association Annual Survey data 2

Contents • • • •

Causal Loops Model Sectors Model Results Discussion

3

Causal Loop Diagram Expected ED wait time

-

percent of gp admits redirected to ED

GP Response to ED Wait Times

ED crowding

Expected wait time for gp referral

ED referrals by gp Redirecting GP referrals to ED

wait time to admit gp referral

total ED visits pressure from payer to reduce hospital use

-

total costs to payers Adjustment to Increasing Costs

Expected costs

4

Emergency Department Sector Population natural ed visits per capita ED visits per 1000

natural ed visits

Total ED Visits total patient hour demand

normal time in ed

desired ed capacity

planning ed capacity chnges time to plan ed changes

ed demand / capacity -

patient hours / bed

Planned ED Capacity



patient hours availabe in ed

ED Capacity ed construction time to construct ed

5

Hospital Sector percent of normal ed visits admited



admits from natural ed visits total admissions

admits from gp referrals to ed admits from ED

percent of gp referral patients admitted

6

General Practitioner Sector normal wait time to admit gp referral

effect of costs on artificial barriers to direct referalls

actual wait time to admit gp referral

Expected wait time fo chg expected wait gp referal for gp referral -

time to adjust expectation

ED referrals by gp

effect of wait time to admit on gp referrals to ed

percent of gp admits redirected to ed

effect of ed wait time on gp referrals to ed

direct admits from gp desired admits from gp total gp visits per year

percent of gp visits requiring hospital admission

gp visits per capita

chng in expected ed wait time



expected ed wait time



7

Payer Sector base cost per admission effect of technology on cost of admission





base inpatient costs to payer tech adjusted inpatient cost



average cost per ED visit

medical technology

ED costs total costs

chng expected costs

expected costs

pressure from payer to reduce hospital use -

time to change expectations

8

The Story • Costs of hospital admissions rose due to factors such as improved medical technology • Payers became alarmed at the cost of hospital admissions • Policies were created to reduce the cost of individual admissions and reduce total admissions • The unintended consequence was more emergency department visits 9

Average Cost per Admission Average Cost per Admission 14000

Average Cost per Admission

12000

10000

8000 Historic Model

6000

No Change 4000

2000

0 1990

1995

2000

2005

2010

2015

Year

(Historic data from U.S. Census Bureau’s statistical abstract) 10

Hospital Admissions by Source 1 0.9 0.8 0.7

Percent

0.6 Historic Admissions from ED

0.5

Model Admissions from ED Historic Admissions from Referrals

0.4

Model Admissions from Referrals

0.3 0.2 0.1 0 1990

1995

2000

2005

2010

2015

Year

(Historic data from Morganti, et al.) 11

Potential Impact of Mechanism • ED visits increased by 15 million between 2003 and 2009 • Inpatient admission from the ED increased by 3.1 million – 3.1 million / 15 million = 20.7% of the total increase in ED visits

12

Discussion • Story of competing interests and unintended consequences • Further investigation warranted • Mechanism behind admission barriers could benefit from further exploration

13

Questions?

14