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Growing Pressures Converge in Hospital Emergency Departments (EDs)

On-Call Coverage, Primary Care Use and More Seriously Mentally Ill Patients Strain Eds

News Release
Nov. 18, 2005

Alwyn Cassil (202) 264-3484 or

WASHINGTON, DC—Converging pressures in hospital emergency departments (EDs)—ranging from persuading specialists to provide on-call coverage to dealing with growing numbers of patients with serious mental illness—have the potential to compromise access to emergency care and spur already rapidly rising health care costs, according to a study released today by the Center for Studying Health System Change (HSC).

The rising pressure in emergency departments is a result of larger forces throughout the health care system, including financial incentives that reward specialist physicians for performing more procedures outside general hospitals; diminishing access to primary care; declining funding for community-based mental health services; and financial pressures on hospitals to pursue business strategies of seeking higher-paying patients and services, the study found.

"Failure to deal with these underlying problems in the health care system threatens to compromise access to emergency care for patients and add to rising health care costs," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation.

Numerous reasons were cited for specialist physicians’ waning interest in taking ED on-call coverage: the perceived higher risk of malpractice litigation, lack of reimbursement for uninsured patients, opportunity costs in terms of time away from their practices and late and unpredictable hours.

"Historically, emergency on-call coverage has been part of a physician’s obligation in return for hospital admitting privileges, and as specialists provide more services outside general hospitals, they are less dependent on having privileges at general hospitals," said HSC Senior Researcher Ann S. O’Malley, M.D., coauthor of the study with HSC Health Research Assistant Anneliese M. Gerland; HSC Senior Researcher Hoangmai H. Pham, M.D.; and HSC Senior Consulting Researcher Robert Berenson, M.D., of the Urban Institute.

Along with providing stand-ready capacity to respond to life-threatening injuries and illnesses ranging from head traumas to heart attacks, emergency departments also serve as the care provider of last resort for insured and uninsured patients alike who cannot access care elsewhere. Emergency departments are the one place in the U.S. health system where—under federal law—people can’t be turned away regardless of their insurance status or ability to pay.

In the face of these pressures, ED visit rates continue to grow steadily. During the past decade, the number of ED visits nationally rose 26 percent—from 90 million to 114 million in 2003—much faster than the 11 percent growth in the U.S. population during the same period.

The study’s findings are detailed in a new HSC Issue Brief—Rising Pressure: Hospital Emergency Departments as Barometers of the Health Care Systemavailable here. The study is based on HSC’s 2005 site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y.

Other key findings of the study include:

  • While the use of emergency departments for primary care is a long-standing problem, hospital, health plan and public-sector respondents in the 12 HSC sites reported the problem has intensified during the last two years.
  • Emergency department directors in the 12 HSC communities indicated growing numbers of seriously mentally ill patients are presenting in emergency departments, creating stress for staff and hampering ED medical functions. Many hospital EDs are ill equipped to meet the needs of mentally ill patients because of inadequate numbers of psychiatric practitioners and beds in many EDs.
  • Many hospitals are expanding and renovating their EDs, in part to attract more insured inpatient admissions. Given the high rates of admission through emergency departments, having a large or full-service ED is one way to ensure a steady flow of insured inpatients and make a hospital appealing to clinicians and patients. In general, ED expansions appear to be motivated by competition for well-insured patients, particularly in affluent locations.

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by The Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.



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The Center for Studying Health System Change Ceased operation on Dec. 31, 2013.