Safety-Net Emergency Departments: A Look at Current Experiences and Challenges

Methods

We conducted semi-structured interviews with ED directors in a convenience sample of 15 safety-net hospitals around the country, to learn how selected aspects of their ED’s experience in the six months immediately following full implementation of the ACA (January-June 2014) compared with their experience in the same six-month period in the year before ACA implementation (January-June 2013). Among those we interviewed were ED medical directors, chairpersons, and chief medical officers. The hospitals included in our sample are located in a mix of Medicaid expansion and non-expansion states and are drawn from all four Census regions. Although we sought to recruit diverse hospitals with respect to urban/suburban/rural location, ownership, and other factors, our sample includes primarily large, urban academic centers with an average of close to 100,000 ED visits per year. On average, the Medicaid share of total inpatient discharges was 42% in the sample hospitals.

Interview Questionnaire

1. Thinking about the period since January 1, 2014, when the ACA-related coverage expansions took effect, has the visit volume in your emergency department changed compared to the first six months of 2013? What do you think is the primary reason for the observed change? What do you anticipate will happen to your visit volume over the next 3-5 years?
2. What is the current insurance (or payor) mix of your ED patients? In other words, roughly what share of patient visits (not revenue or charges) are attributable to Medicaid, Medicare, privately insured, and self-pay/uninsured patients, respectively? Has this insurance mix changed compared to the first six months of 2013? If so, how?
3. Compared to the first six months of 2013, has patient acuity in your emergency department changed since January 1, 2014? If yes, please elaborate – for example, have you seen a change in fast-track volume, admission rates, or triage acuity categories?
4. Approximately what share of your emergency department patients would you say currently have a primary care doctor or a clinic they usually go to? Is this share about the same as it was in the first six months of 2013, or is it different?
5. How often does your emergency department see patients who are visiting the emergency department because they do not have other access to timely primary care? Specialty care?
6. What is the typical “boarding time” for an admitted psychiatric patient in your emergency department (i.e., disposition decision to emergency department departure)? Is this about the same compared to the first six months of 2013 or is it different?
7. How, if at all, have the changes in the ACA affected your ED’s finances?
8. What do you see as the chief opportunities and challenges presented by the ACA?
9. Is there anything we haven’t covered that you’d like to observe or share?