In the last 20 years, the number of hospital emergency departments (EDs), in non-rural areas in the United States has declined by nearly 30%, with for-profit ownership, location in a competitive market, low profit margin and safety-net status associated with an increased risk of emergency department closure, according to a study in JAMA.
“As the only place in the U.S. health care system that serves all patients, emergency departments are the ‘safety net of the safety net.’ Federal law requires hospital EDs to evaluate and treat all patients in need of emergency care regardless of ability to pay,” the study authors wrote. “Between 1998 and 2008, the number of hospital-based EDs in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures.”
Renee Y. Hsia, MD, MSc, of the University of California, San Francisco, and colleagues conducted a study to examine the factors that may be associated with the closure of hospital EDs. The study included EDs and hospital organizational information from 1990 through 2009, acquired from the American Hospital Association Annual Surveys and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports.
The researchers found that from 1990 to 2009, the number of hospitals with EDs in non-rural areas in the United States decreased from 2,446 to 1,779, a decline of 27%, with an average of 89 closing per year. Over an 18-year study interval (1990-2007), EDs that closed were more likely to be at for-profit hospitals than EDs that remained open (26% vs. 16%). Smaller facilities were more likely to close their ED; and twice as many hospitals that closed their EDs were in the lowest quartile of the profit margin distribution, compared with those that kept their EDs open. EDs that closed tended to be located in counties with high shares of minority populations (36% vs. 31%), high shares of populations in poverty (37% vs. 31%), and more than 15% of its individuals without insurance (42% vs. 36%). Thirty-four percent of EDs that closed were in highly competitive markets, compared with 17% of those with EDs that did not close.
“Our findings underscore that market-based approaches to health care do not ensure that care will be equitably distributed. In fact, the opposite may be true. As long as tens of millions of Americans are uninsured, and tens of millions more pay well below their cost of care, the push for ‘results-driven competition’ will not correct system-level disparities that markets cannot— and should not—be expected to resolve,” the authors wrote.