JAMA: 27% of EDs have closed, mostly due to costs

Twenty-seven percent of rural hospital emergency departments closed between 1990 and 2009, and reasons for these closures were linked to market competition, safety-net status and a low profit margin, among other factors, according to the results of a study published in the May 18 issue of the Journal of the American Medical Association.

“As the only place in the U.S. healthcare system that serves all patients, emergency departments (EDs) are the 'safety net of the safety net,'” Renee Y. Hsia, MD, of the University of California, San Francisco, and colleagues wrote. “Federal law requires hospital EDs to evaluate and treat all patients in need of emergency care regardless of ability to pay.”

While a mere 4 percent of U.S. physicians work within hospital EDs, these physicians provide more acute care to Medicaid beneficiaries than the rest of U.S. physicians combined. The number of hospital-based EDs declined 3.3 percent between 1998 and 2008, and Hsia et al looked to understand the market forces that influence access to care and the risk factors associated with ED closures.

To do so, Hsia and colleagues gathered American Hospital Association annual survey data between 1990 and 2009 and merged data with hospital financial and payor mix information through 2007 from Medicare hospitals cost reports. Hsia et al evaluated risk factors including hospital characteristics, population demographics and market factors. The study included 2,446 general, acute, nonrural, short-stay hospitals in the U.S. operating an ED between 1990 and 2009.

The researchers used ED closure during the study period as the primary outcome.

Hsia and colleagues reported that between 1990 and 2009, the number of hospitals in nonrural areas declined from 2,446 to 1,779 (27 percent) and 1,041 EDs closed (an average of 89 per year). Of the 1,041 ED closures, 66 percent were due to closure of the entire hospital and 34 percent were ED-only closures within a hospital. During the duration of the study, 374 hospitals opened EDs.

The researchers observed that for-profit hospitals and those with low profit margins were more apt to close compared with not-for-profit hospitals or government hospitals; hospitals located in more competitive markets also had higher risks of closing. Safety-net hospitals and hospitals surrounded by greater poverty were also more likely to close compared to their counterparts, 10 percent vs. 6 percent and 37 percent vs. 31 percent, respectively.

“Safety-net hospitals are at higher risk of closing their EDs compared with non-safety-net hospitals, suggesting that safety-net hospital status reflects other pressures that, although less measurable, are associated with ED closure,” the authors wrote. “While this finding deserves more study, it signals that safety-net hospitals may require particular attention if emergency care access is to be sustained.”

Hospitals who served greater percentages of minority populations and those located in communities where more than 15 percent of the population was uninsured also had higher rates of ED closure, the researchers noted. The researchers called these results “compelling” due to the fact that a greater number of vulnerable populations (minority groups and the uninsured) use more acute care.

“As more of these patients lose access to primary care, an increasing number of EDs are meeting criteria as safety-net facilities, which suggests that more EDs may be at risk of closing in the future,” the authors wrote. “ED closures can have substantial effects on vulnerable communities, causing a decline in care as hospitals serving poor and minority populations select to provide services based on profitability rather than community health needs.”

Additionally, the researchers noted that while a business strategy within U.S. hospitals has been to decrease the number of patients treated to decrease uncompensated costs, EDs cannot do so, especially as the number of Medicare patients continues to rise.

Congress called for the closure of hospital EDs nearly two decades ago; however, the researchers noted that these measures are “difficult to enact and even harder to implement.”

“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 concluded.