Emergency departments: The economic engine of hospitals – Evidence from California

Journal Pre-proof Emergency departments: The economic engine of hospitals – Evidence from California

Glenn Melnick, Katya Fonkych, Luis Abrishamian PII:

S0735-6757(19)30827-7

DOI:

https://doi.org/10.1016/j.ajem.2019.12.021

Reference:

YAJEM 158649

To appear in:

American Journal of Emergency Medicine

Received date:

12 September 2019

Revised date:

12 December 2019

Accepted date:

13 December 2019

Please cite this article as: G. Melnick, K. Fonkych and L. Abrishamian, Emergency departments: The economic engine of hospitals – Evidence from California, American Journal of Emergency Medicine(2018), https://doi.org/10.1016/j.ajem.2019.12.021

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© 2018 Published by Elsevier.

Journal Pre-proof Title Page

Emergency Departments: The Economic Engine of Hospitals -Evidence from California

Authors:

Dr. Glenn Melnick, Ph.Di, Katya Fonkych, Ph.Dii, Luis Abrishamian, MDiii

External Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure Statement:

Conflict of Interest: None of the authors of this study have conflicts of interest to report.

Keywords:

EDs, Emergency Departments, Emergency Department Utilization

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Title:

Journal Pre-proof Emergency Departments: The Economic Engine of Hospitals – Evidence from California 1. Introduction and Background: From the first hospital in the United States, founded in 1753 in Philadelphia with the help of Benjamin Franklin, hospitals have been an increasingly important part of the evolving health care landscape in America. Hospital-based emergency departments (EDs), though initially a small part of overall operations, also grew as part of the

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increased importance of hospital-based medicine following World War IIiv. ED staffing was

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largely based on part-time coverage by community physicians, rotating house officers, or

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doctoring working part time from other jobs. Beginning in the late 1970s hospitals began staffing

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their EDs with full-time, around-the-clock coverage including residency-trained, board-certified emergency physicians. This remains the model in today’s modern hospitalv. At the same time,

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the role and structure of hospitals in the US has continued to evolve in substantial ways. While

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many aspects of the growth and evolution of hospitals have been studied in the literature, the growing importance and impact of emergency departments and ED physicians within US

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hospitals has received less attention.

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2. Materials and Methods

2.1 Study Design and Setting: We conducted a secondary analysis of hospital reported, publicly available capacity, utilization, and charge data covering inpatient admissions, including admissions through EDs, and hospital outpatient visits, including ED visits, for all general acute care hospitals in California between 2002 through 2017.

2.2 Data and Methods of Measurement: Each hospital in California files a series of annual reports with the California Office of Statewide Health Planning and Development (OSHPD)

Journal Pre-proof providing detailed capacity, utilization, and financial statistics. OSHPD data are considered among the most reliable public health care data sources and are widely used by academic researchers. STATA and Excel software were used to construct the following outcome measures: Hospital ED Capacity and Utilization: OSPHD Annual Hospital Utilization data are used to

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calculate hospital ED capacity and utilization outcome measures for all general acute care

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2012, 2017) to document trends over the study period:

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hospitals over time a 16-year study period. We present findings for selected years (2002, 2007,

Total Hospital Based EDs and ED Treatment Stations: The total number of general

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acute care hospitals with licensed EDs and without EDs are calculated in each year.

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Hospitals with EDs were subdivided into categories based on whether they were

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designated as a trauma center and designation level (Level I = highest designation, IV= lowest designation). The total number of hospitals in each category was calculated along

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with the total number of ED treatment stations for each year. California population totals

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are drawn from the US Census Bureau. Inpatient Admissions: The total number of inpatient admissions across all hospitals in each year separately for patients admitted through the ED, all other (non-ED) admissions and total inpatient admissionsvi. These totals are used to calculate the percentage of total inpatient admissions admitted through the ED along with other calculations described below. ED Visits: Different categories of ED visits are calculated including ED visits for patients treated as outpatients (treat and release in the same day), ED visits resulting in an

Journal Pre-proof inpatient admission, and total ED visits across all hospitals in each year and separately for hospitals based on trauma center designation status and level. Charge Weighted ED Utilization: To measure the economic effects of ED generated utilization on overall hospital operations we calculate charge weighted ED and non-ED generated inpatient and outpatient hospital utilization (due to data limitations, ED physician charges are not

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included). Hospital charges are a commonly used measure for measuring the relative resource use of different services within hospitals and assumes that patients with higher charges within a

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hospital consume greater resources relative to lower charge patients. This assumption is

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consistent with the approach that Centers for Medicare and Medicaid services (CMS) applies by

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using charges to allocate costs in developing its reimbursement rates under the Medicare

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develop improved measurement.

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program. We discuss the limitations of this approach below and the need for future research to

Inpatient ED Charges and Non-ED Charges: All hospitals in California report to

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OSHPD detailed patient level discharge records (Patient Discharge Data, PDD) for all

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inpatient admissions for each year including the total amount charged for each patient (including all daily service and ancillary services associated with the admission). We use the PDD data (2002 and 2016, most recent year available) to calculate the total number of inpatient admissions, total charges and average charge per admission across all hospitals in each year separately for patients admitted through the ED, all other (non-ED) admissions and total inpatient admissions for all general acute care hospitals. We use the average charge per admission for ED and non-ED admissions to calculate the ratio of average charge for ED patients to non-ED admissions as a measure of relative resource use between the two groups.

Journal Pre-proof Outpatient ED Visit Charges: Unlike inpatient utilization, OSHPD does not collect data on total charges at either the visit level nor at the ED level but rather reports total outpatient charges and total outpatient visits, by type of visit. Our methodology is designed to estimate the share of total outpatient charges associated with ED visits (relative to non-ED outpatient visits) using selected measures from the Annual Financial data reported by all hospitals OSHPD each year. We first calculate the average charge

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per outpatient visit across all visits combined at each hospital by dividing total outpatient

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charges for all visits by total outpatient visits (combined) at each hospital in each year.

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We then conduct a regression to estimate the relative charge weight for each type of visit.

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The regression model uses average charge per visit as the dependent variable and the percentage of total visits in each of the following visit categories (n=5) as reported to

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OSHPD as the explanatory factors: ED visits, clinic visits, referred outpatient visits,

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home health visits, and outpatient surgery visits. The relative charge weights for each visit type are then multiplied by the share of total visits for each of the five visit

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categories to calculate the share of total outpatient charges associated with each type of

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visit. The ED visit share is multiplied by total outpatient charges to estimate total outpatient charges associated with ED visits in each year. Due to hospital accounting practices and data limitations, the relative charge weights for ED visits using this approach: 1) may over-estimate ED share of total charges if hospitals with higher relative charges for ED visits also have higher shares of total visits that ED visits, and 2) underestimate average charge per ED visit since the numerator incudes total outpatient charges (only) all the denominator includes all ED visits, including those that are admitted as

Journal Pre-proof inpatients and therefore are not assigned any outpatient charges within hospital accounting systems. ED Charges Share of Total Hospital Charges: The Annual Financial reports include data on total hospital charges and total charges for inpatient services and outpatient services separately which are used to calculate the totals and share of total charges related

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to inpatient services and outpatient services across all general acute care hospitals in each year. The estimated ED related relative charges for inpatient services and outpatient

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services described above are used to estimate the share of total charges associated with

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ED services in each year.

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3.0 Results

3.1 ED Capacity: Table 1 data show substantial expansion of hospital ED capacity. While

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population grew by 14% over the study period, the total number of general acute care hospitals (2%) and proportion of total hospitals with licensed emergency departments (86%-88%) remained

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fairly constant. Hospitals with EDs, however, substantially expanded their internal capacity ---

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the total number of ED treatment stations within EDs increased 49% and per capita ED treatment stations increased 30%. Twenty-one hospitals upgraded their EDs to receive trauma center designation: in 2002 only 17% of hospitals with EDs were designated trauma centers and by 2017 almost one out of four EDs had achieved trauma designation, with the growth in trauma centers led by Level II trauma centers. In total, the total number of designated trauma centers increased by 39%. 3.2 ED Utilization: Table 2 summarizes trends in ED utilization including outpatient OP ED visits (treat and release in the same day) and ED visits resulting in an inpatient admission. Total

Journal Pre-proof ED visits grew substantially between 2002 and 2017(61%), outpacing growth in both population (14%) and ED treatment stations per capita (30%). Trauma designated EDs saw the largest percentage increase in total ED visits (109%), due in part to their increased capacity (39%) and compared to non-trauma EDs (46%). ED visits resulting in an inpatient admission also grew substantially from 1.160 million to 1.885 million (63%) between 2002 and 2017 and the share of total inpatient admissions through EDs grew from less than half (37%) in 2002 to more than half

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(60%) in 2017. When maternity admissions are excluded from the total, the share of ED based

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admissions increases to 69% in 2017. Consistent with other studies, the upward trend in ED

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utilization is already evident by 2012 and, as such, does not appear to be largely driven by

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implementation of the Affordable Care Act in 2014vii,viii.

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3.3 ED Generated Charges: Table 3 presents estimated charge weighted ED utilization in 2002 and 2017 for inpatient admissions through the ED, outpatient (treat and release) ED visits, and

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share of total hospital charges generated by all ED based utilization. The top panel of Table 3

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shows that the share of total hospital charges generated by all inpatient admissions declined from 74% to 62% while the share of total hospital charges generated by all outpatient utilization

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increased from 26% to 38%. Calculations for charges flowing from ED generated inpatient utilization show that ED based admissions accounted for 41% of total inpatient hospital charges in 2002 (in 2002 ED admissions accounted for 37% of all admissions and the average charge per admission for ED patients was 110% of (10% above) the average charge for non-ED inpatients, resulting in a slight increase in the charge weighted value of ED admissions from 37% to 41% of total inpatient charges). As discussed above, by 2017 the share of total inpatient admissions through the ED grew substantially, to 60%, while the average charge per admission for ED patients relative to non-ED patients also grew substantially, to 127% (27% above). As a result,

Journal Pre-proof the charge weighted utilization of ED driven inpatient admissions grew to account for 76% of total inpatient charges in 2017. The middle panel of Table 3 shows calculations for ED generated charges flowing from outpatient ED visits. In 2002, ED visits accounted for 19% of total hospital outpatient visits and average charge per ED visit is estimated at 206% of the average charge for all other non-ED visits, resulting in charge weighted value of ED utilization of 39% of total outpatient charges. By

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2017 the share of total hospital outpatient visits coming through the ED increased to 26% of all

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outpatient visits while the average charge per visit for ED patients relative to non-ED patients

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declined slightly to 195% (95% above). As a result, the share of total hospital outpatient charges

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derived from ED visits increased to 51% in 2017, up from 39% in 2002.

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The bottom panel of Table 3 shows the combined effect of these two trends on the share of total charges generated by inpatient and outpatient ED utilization. The share of total hospital charges

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2017.

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generated by ED based inpatient and outpatient utilization increased from 40% in 2002 to 67% in

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4. Discussion and Limitations: Hospitals continue to play a major role in our health care delivery system. Hospitals, at their peak in 1982 accounted for about 40% of national health care spending and 33% today. Our data show that the role of EDs within hospitals and correspondingly the role of ED physicians has expanded substantially over time. On the inpatient side, hospital EDs and therefore ED physicians are now the main source of inpatient admissions to the hospital – 60% of all admissions and 69% all non-maternity admissions. On a charge weighted basis, ED based admissions grew from 41% of all inpatient charges in 2002 to 76% of all inpatient charges by 2017. On the outpatient side, ED capacity and total ED visits have also grown. ED visits now account for 51% of total outpatient charges, up from 39% in 2002.

Journal Pre-proof Overall, ED generated volume accounts for more than two-thirds of total hospital charges (67%) in 2017 compared to 40% in 2002. While our study does not seek to explain the factors driving the larger and expanded role of EDs within hospitals, studies in the literature offer some insight into the factors that have contributed to EDs expansion. Government regulations explicitly expanded access to and utilization of hospital-based EDs. The Emergency Medical Treatment and Active Labor Act (EMTALA),

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enacted in 1986 requires that hospitals with EDs screen and provide treatment to patients with

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emergent conditions regardless of a patient’s ability to payix. This expanded access to EDs and

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made EDs a safety-net provider for the uninsured. Beginning in late 1990’s, most states,

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including California, adopted “prudent layperson” regulations requiring that health plans instruct

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their members to go to the nearest hospital in the event of a medical emergency and that plans will cover the cost of their care, even if the nearest hospital is out of network with their plan,x,xi.

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Hospital ED visit rates increased substantially after implementation of these lawsxii. EDs have

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become important to fill gaps in the delivery system by providing a reliable source of after-hours care and by providing behavioral health care, often when such care is not otherwise

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availablexiii,xiv,xv,xvi. EDs increasingly provide services historically provided by primary care providers (PCPs), including diagnostic testing (e.g., blood testing) and coordinating chronic care (e.g., care to manage a chronic disease such as diabetes)xvii. A 2013 study by RAND found that EDs provide back-up to office based primary care and specialty practices by performing complex diagnostic workups and handling overflow, after-hours, and weekend demand for carexviii. Our health care delivery system is dynamic and is continuing to evolve in ways that might impact the future role of hospital based EDs including new outpatient health care models being developed to substitute for some care currently delivered in EDs. Retail clinics provide

Journal Pre-proof unscheduled routine primary care for a limited range non-emergency conditions currently treated in hospital EDs while urgent care clinics offer unscheduled and after-hours access to care for a wider range of services. Hospitals in some states are establishing free-standing emergency rooms designed to function like an ED but are physically separate from hospitals. Hospital owned free standing EDs are subject to EMTALA while others, owned by private investment groups or ED physicians, are currently exempt from EMTALA regulations. The limited research to date

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provides a mixed picture of how these various alternative models will affect the future role and

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utilization of hospital based EDsxix,xx.

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Finally, new payment models, such as accountable care organizations or medical homes, adopted

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by the Federal government and private insurance companies designed to foster care coordination

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for patients across care setting could impact future ED utilization patternsxxi by reducing exacerbations of chronic conditions and assuring effective post discharge follow up and care

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coordination. Given the expanded role of EDs, new models of ED based interdisciplinary care teams might be expanded and integrated into these broader efforts to improve health system

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outcomes and valuexxii. Better integration of EDs into hospital and health system IT systems

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that combine patient medical data across settings would greatly facilitate the care coordination role of ED physicians.

Limitations: Our goal is to quantify the total impact of ED generated utilization (inpatient + outpatient) on overall hospital economic activity. Available data allow measurement of ED based utilization directly using standard outcome measures (inpatient admissions and OP visits). Based on these measures the share of inpatients and outpatient visits generated by EDs increased substantially over the last 15 years. To estimate the impact of ED utilization on hospital economic activity we follow others in the literature to weight inpatient admissions and outpatient

Journal Pre-proof ED visits by chargesxxiii. OSHPD data allow direct measurement of total charges for each inpatient ED admission but do not provide a direct measure of charges for ED visits. We use a regression model to apportion outpatient charges to ED visits (versus all other non-ED visits). This approach may introduce errors since hospital level charges are known to vary considerably across hospitals for the same service and could be biased upward if hospitals with more ED visits and higher inpatient admissions through the ED also have higher charges for ED visits. While

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future research and improvements in hospital accounting and reporting are needed to provide

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better understanding of the impacts of ED and non-ED based utilization on hospital resources,

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costs, and net revenues, our results provide a valuable baseline to build uponxxiv. Finally, while

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our data are from a single state, California, is a large state with a large, diverse sample of hospitals operating under different market conditions and national data sources covering the

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entire country report similar trends to those documented here for Californiaxxv,xxvi,xxvii,xxviii.

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5. Conclusions: In summary, hospital EDs and ED physicians, now account for the majority of

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inpatient hospital admissions and a large and growing share of hospital-based outpatient care. California ED physicians (4,842 in CA; 39,547 in the US, 2015), while accounting for only 4.8%

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of total CA physicians (4.6% in US), now play a much expanded role beyond their numbers in our overall health care delivery systemxxix. At the same time, there has been emergence and growth of large corporate contract management groups and hospital ownership of vertically integrated physician groups including ED physiciansxxx. These entities, depending on their size and geographic concentration, have the potential to both drive up prices to consumers while at the same time reducing ED physician compensationxxxi. These findings may have important and widespread policy and health system design implications meriting further research.

Journal Pre-proof Research is needed to better understand the value proposition for hospital-based outpatient emergency services to develop incentives and policies for their optimal usexxxii. The large and growing fraction of total hospital admissions that are emergency admissions has important implications for the pricing of hospital services under contracts with commercial health insurance plans. Unlike Medicare, commercial health plans negotiate contract terms with hospitals based on market conditions. Some have argued that the large share of admissions

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through EDs has reduced price competition amongst hospitals and will result in long term price

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increasesxxxiii.

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Finally, research is needed to better understand the expanded role of ED physicians to ensure that

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their education and training has kept up with these changes and that we are training and

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graduating the right number and mix of ED physicians to fill this expanded rolexxxiv,xxxv. And for the long run, we need to understand how ED physicians can be more effectively integrated into

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the senior management structure and overall strategic governance of hospitals and into broader delivery system to enhance efforts to improve health status, coordinate care, improve quality and

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reduce our rising health care costs xxxvi,xxxvii.

Corresponding Author: Professor and Blue Cross of California Chair, Price School of Public Policy, University of Southern California, Lewis Hall 312, Los Angeles, California 90089-0626 Email: [email protected], Phone: 310-499-3125, Mailing Address: 2205 North Meadows Ave Manhattan Beach, CA 90266 ii

Associate Researcher, Center for Health Financing, Policy and Management, Price School of Public Policy, University of Southern California, Lewis Hall 312, Los Angeles, California 90089-0626 Email: [email protected] Phone: 310-460-8673 iii

Emergency Medicine Physician, Providence Little Company of Mary Medical Center, 4101 Torrance Blvd, Torrance, CA 90503

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Email: [email protected] Phone: 310-560-9964 iv

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Arthur L. Kellermann, and Ricardo Martinez, “The ER, 50 Years On”, N Engl J Med 2011; 364:2278-2279, DOI: 10.1056/NEJMp1101544 v Institute of Medicine (IOM), 2007. Emergency Medical Services: At the Crossroads. Washington, DC: The National Academies Press. vi OSPHD reports discharges that occurred during a given reporting period. We use the terms admissions and discharges inter-changeably. vii McCconville, S., Danielson, C., Hsia, R., Emergency Department Use in California: Demographics, Trends, and the Impact of the ACA, Public Policy Institute of California, February 2019.

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HTTPS://WWW.PPIC.ORG/PUBLICATION/EMERGENCY-DEPARTMENT-USE-INCALIFORNIA-DEMOGRAPHICS-TRENDS-AND-THE-IMPACT-OF-THE-ACA/ viii

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Shannon McConville, Maria C. Raven, Sarah H. Sabbagh, and Renee Y. Hsia, Frequent Emergency Department Users: A Statewide Comparison Before And After Affordable Care Act Implementation, HEALTH AFFAIRSVOL. 37, NO. 6: JUNE 2018 ix

xiv

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Mark M. Moy, The EMTALA Answer Book: 2009 Edition (Wolters Kluwer Law & Business, 2009), p. xxxiv. x Hall, Mark. (2004). The Impact and Enforcement of Prudent Layperson Laws. Annals of emergency medicine. 43. 558-66. 10.1016/S0196064403013416. xi Williams RM. The prudent layperson definition: will it work for emergency medicine?. Annals of emergency medicine. 2000 Sep 1;36(3):238-40. xii A. Melnick, Glenn & Fonkych, Katya & Zwanziger, Jack. (2018). The California Competitive Model: How Has It Fared, And What’s Next?. Health Affairs. 37. 1417-1424. 10.1377/hlthaff.2018.0418. xiii Institute of Medicine of the National Academies, Hospital-Based Emergency Care: At the Breaking Point (Washington, DC: National Academies Press, 2006). Renee M. Gindi and Lindsey I. Jones, Reasons for Emergency Room Use Among U.S. Children: National Health Interview Survey, 2012, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, NCHS Data Brief: No. 160, Hyattsville, MD, July 2014. xv Jessamy Taylor, Don't Bring Me Your Tired, Your Poor: The Crowded State of America’s Emergency Departments, National Health Policy Forum, Issue Brief-No. 811, Washington, DC, July 7, 2006 xvi Anne Manton, Care of the Psychiatric Patient in the Emergency Department, Emergency Nurses Association, white paper, Des Plaines, IL, February 2013, http://www.ena.org/practiceresearch/research/Documents/ WhitePaperCareofPsych.pdf. xvii Stephen R. Pitts et al., “Where Americans Get Acute Care: Increasingly, It’s Not at Their Doctor’s Office.” Health Affairs, vol. 29, no. 9 (September 2010), pp. 1620-1629. xviii Gonzalez Morganti, Kristy, Sebastian Bauhoff, Janice C. Blanchard, Mahshid Abir, Alexandria Smith, Joseph Vesely, Edward N. Okeke, Arthur L. Kellermann, and Neema Iyer,

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The Evolving Roles of Emergency Departments. Santa Monica, CA: RAND Corporation, 2013. https://www.rand.org/pubs/research_briefs/RB9715.html. xix Robin M. Weinick, Rachel M. Burns, and Ateev Mehrotra, “Many Emergency Department Visits Could Be Managed at Urgent Care Centers and Retail Clinics,” Health Affairs, vol. 29, no. 9 (September 2010), pp. 1630-1633 xx Alexa Ura, “Texas Hospitals Say They’ve Lost Insured Patients to Urgent Care,” The New York Times, August 29, 2014, p. A19A, National Edition xxi ACOs (Shared Savings Program) were established in Section 1899; (42 U.S.C. §1395jjj of the Social Security Act (SSA)). See CMS, “What’s an ACO?” http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/ index.html?redirect=/ACO. xxii Samantha Roy, Fernando Reyes, Sarah Himmelrich, Lauren Johnston, and Dave A. Chokshi,, “ Learnings from a Large-Scale Emergency Department Care Management Program in New York City” Catalyst.Nejm.org, February 7, 2018. https://catalyst.nejm.org/ed-caremanagement-program-nyc/ xxiii

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Casey R.Tak, Marty C.Malheiro, Heather K.W.Bennett, Barbara I.Crouch, “The value of a poison control center in preventing unnecessary ED visits and hospital charges: A multi-year analysis”, The American Journal of Emergency Medicine, October 2016. xxiv

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We cross checked our findings for a Los Angeles hospital and based on their internal accounting data we were able to confirm/validate our results for their facility. xxv Gonzalez Morganti, Kristy, Sebastian Bauhoff, Janice C. Blanchard, Mahshid Abir, Alexandria Smith, Joseph Vesely, Edward N. Okeke, Arthur L. Kellermann, and Neema Iyer, The Evolving Roles of Emergency Departments. Santa Monica, CA: RAND Corporation, 2013. https://www.rand.org/pubs/research_briefs/RB9715.html. xxvi Schuur, Jeremiah & Venkatesh, Arjun. (2012). The Growing Role of Emergency Departments in Hospital Admissions. The New England journal of medicine. 367. 391-3. 10.1056/NEJMp1204431. xxvii David Marcozzi, Brendan Carr, Alisha Liferidge, Nicole Baehr, Brian Browne. Trends in the Contribution of Emergency Departments to the Provision of Health Care in the USA. International Journal of Health Services, 2017; 002073141773449 DOI: 10.1177/0020731417734498 xxviii Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010 Aug 11;304(6):664–670. xxix

https://www.aamc.org/data/workforce/reports/492556/1-1-chart.html

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Derlet, Robert W. et al., Corporate and Hospital Profiteering in Emergency Medicine: Problems of the Past, Present, and Future, Journal of Emergency Medicine, Volume 50, Issue 6, 902 – 909. xxxi

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Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A. Emergency department visits for nonurgent conditions: systematic literature review. Am J Manag Care. 2013;19(1):47-59. xxxiii

A. Melnick, Glenn & Fonkych, Katya & Zwanziger, Jack. (2018). The California Competitive Model: How Has It Fared, And What’s Next?. Health Affairs. 37. 1417-1424. 10.1377/hlthaff.2018.0418. xxxiv Hoelle RM, Vega T, Atanelov Z, and Toklu H, “ Emergency medicine residency programs: the changing face of graduate medical education”, Int J Med Educ. 2018 Jan 16;9:9-10. doi: 10.5116/ijme.5a47.8274. xxxv

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Hill AD, “Emergency Medicine Residencies Are Failing Main Street America”, J Emerg Med. 2018 Oct;55(4):534-536. doi: 10.1016/j.jemermed.2018.06.004. Epub 2018 Jul 23. xxxvi

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Schneider, Sandra M. et al., “The Future of Emergency Medicine” Annals of Emergency Medicine , Volume 56 , Issue 2 , 178 - 183 xxxvii

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Goldstone M,, ”Leadership and the future of emergency systems”, Ann Emerg Med. 2007 Feb;49(2):247-8.

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Table 1: Emergency Department (ED) and Trauma Center Capacity

59 12 29 9 9

-2 2,542

-1% 49%

190

197

45

30%

69 13 34 13 9

75 13 37 14 11

21 1 9 4 7

39% 8% 32% 40% 175%

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Sources: OSPHD: Annual Hospital Utilization Files; Bureau of Census

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% Change 2002-2017 -2% 14%

318 7,780

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167

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54 12 28 10 4

2017 362 39.4

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325 335 6,058 7,235

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ED Trauma Center Capacity Designated Trauma Centers - Total Trauma Level I Trauma Level II Trauma Level III Trauma Level IV

320 5,238 152

2012 382 38.0

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ED Capacity - Overall General Acute Care Hospitals with Licensed EDs ED Treatment Stations ED treatment stations per population (per million)

2007 370 36.2

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Total Hospitals - General Acute Care CA Population (million)

2002 371 34.5

Change (#) 2002-2017 -9 4.9

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Table 2: Emergency Department Utilization

2017

% % Change Change

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2002 2017

37%

61%

3,561,219

4,489,784

66%

109%

6,777,778

7,655,533

8,669,339

9,863,257

28%

46%

1,643,563

1,803,772

1,885,232

56%

63%

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2,484,226

1,159,926 3,166,809

3,289,964

3,213,960

3,168,446

1%

0%

37%

50%

56%

60%

51%

62%

496,176

536,806

481,727

450,593

-3%

-9%

60%

66%

69%

52%

60%

43%

Source: OSPHD: Annual Hospital Utilization Files

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2002 2012

2,143,775

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Total Maternity Admissions Percentage of Total NonMaternity Admissions Admitted through ED

2012

8,921,553 10,139,759 12,230,558 14,353,041

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ED Visits, Total (Admitted + Outpatient ED Treat and Release), All Hospitals w EDs ED Visits, Total, Trauma Centers ED Visits, Total, Non- Trauma Centers ED Visits Resulting in Admission - Total Hospital Admissions - Total (ED and Non-ED) Percentage of Total Admissions Admitted through ED

2007

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2002

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Table 3: Charge Weighted ED Utilization: Inpatient, Outpatient, and Total 2002

2017

Total Inpatient Utilization Charges (ED and Non-ED) as a Percent of Total Hospital Charges

74%

62%

Total Outpatient Utilization Charges (ED and Non-ED) as a Percent of Total Hospital Charges

26%

38%

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Inpatient and Outpatient Share of Total Hospital Charges

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Inpatient ED Charges ED Admissions - Average Charge per Admission Non-ED Admissions - Average Charge per Admission Average Charge per Admission - Ratio, ED to Non-ED Admissions Through ED - Percent Total Admissions Inpatient Charges from ED Admissions as a Percent of Total Inpatient Charges

31,469 28,659 110% 37% 41%

$ $

97,962 77,386 127% 60% 76%

2002 19%

2017 26%

206%

195%

Outpatient Charges from ED Visits as a Percent of Total Outpatient Charges

39%

51%

ED Charges Share of Total Hospital Charges Percent of Total Inpatient Charges from ED Admissions Percent of Total Outpatient Charges from ED Outpatient Visits

2002 41% 39%

2017 76% 51%

Percent of Total Charges from ED Inpatient Admissions Percent of Total Charges from ED Outpatient Visits

30% 10%

47% 19%

Percent Total Hospital Charges from Total ED Generated Utilization (ED Inpatient Admissions and ED Outpatient Visits)

40%

67%

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Outpatient ED Charges ED Outpatient Treat and Release Visits as a Percent of All Outpatient Visits Average Charge per ED Visit – Ratio, ED Visit to All Other NonED Outpatient Visits

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Sources: OSPHD: Annual Financial Pivot Files, Patient Discharge Data (PDD) Files, Annual Hospital Utilization Files

Journal Pre-proof

Author Contribution Authors:

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#1: Dr. Melnick

#3: Abrishamian

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Contribution Area Authors Contributing (by #) Conceptualization 1,2,3 Methodology 1,2 Software 1,2 Validation 1,2,3 Formal analysis 1,2 Data Curation 1,2 Writing: Original Draft 1,2 Review & Editing 1,2,3

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#2: Dr. Fonkych