2010 Testimony

2009 Testimony

Introduction

Chairman Tasco, I am Pam Clarke, Vice President of Health Care Finance and Managed Care for the Delaware Valley Healthcare Council of HAP (DVHC). DVHC represents and advocates for more than 100 acute care, pediatric, rehabilitation, behavioral health, and specialty care health systems, hospitals, and facilities and the patients they serve in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. DVHC is part of The Hospital & Healthsystem Association of Pennsylvania (HAP), which represents and advocates for more than 250 acute and specialty care hospitals and health systems across the state.

I appreciate the opportunity to testify today about Philadelphia hospitals’ commitment to providing the best possible health care for their patients and communities. Specifically, I will provide background about the steps hospitals take to meet and exceed guidelines and regulations for the operation of Emergency Departments (EDs) in order to deliver a wide range of high-quality health care services in the face of significant challenges.

My testimony will provide an overview of:

• Guidelines and regulations pertaining to hospital emergency care.
• The patients and communities served by Philadelphia emergency departments, or EDs.
• The wide array of services and high level of care EDs provide.
• The challenges hospitals overcome to provide these crucial health care services to Philadelphians.
• Innovations hospitals are investing in to provide the best care for all who come through their doors.

Emergency Departments in the State and Region

Hospital-based emergency departments represent a crucial and essential component of Pennsylvania’s health care system. Each day an average of 2,500 people seek medical care in Philadelphia’s 15 EDs, the only health care resources in the City staffed 24/7 and equipped to respond to patients with widely differing types and severity of medical conditions and injuries. During fiscal year 2008, Philadelphia EDs had 900,000 patient visits. About 20 percent of these resulted in hospitalizations. Many Philadelphians rely upon emergency departments as their primary or sole medical care providers, due to economic constraints and/or limited access to primary care, psychiatric, and other specialty physicians. Others use emergency departments as portals of entry into the health care system. Emergency departments truly represent the “safety net” for medical care in the City, region, and state.

Emergency Department Guidelines and Regulations

As part of their mission and by federal law, under the Emergency Medical Treatment and Labor Act (EMTALA), hospital EDs must screen and stabilize all patients regardless of their ability to pay. Philadelphia hospitals embrace this responsibility. In addition to caring for all who turn to them, hospitals devote additional resources such as financial counselors and social workers to help patients as needed with insurance options, financial assistance, and social services. To our knowledge, Philadelphia hospitals have adhered faithfully to EMTALA requirements and have not incurred fines or penalties during the last five years and, most probably, much longer.

The Pennsylvania Department of Health (PA DOH) governs the licensing and regulation of Philadelphia hospitals, including their ED services. PA DOH guidelines require that regardless of the scope of services offered, every hospital must institute essential life-saving measures and provide emergency procedures that will minimize aggravation of the condition of patients during transportation when referral is indicated. Hospitals must have established procedures whereby the ill or injured person can be assessed and either treated, referred to an appropriate facility, or discharged, as indicated. Emergency care must be guided by written policies and procedures. Hospitals in Philadelphia and across the state have developed extensive policies and procedures for all aspects of hospital care, including emergency services. In the complex, rapidly changing world of modern medicine, these measures are crucial to hospital operations. Every two years, PA DOH surveys hospitals, including emergency departments, for compliance with these regulations. In addition, PA DOH conducts annual surveys of Pennsylvania hospitals to ensure that they meet criteria set by the Centers for Medicare & Medicaid Services for Medicare Condition of Participation.

All Philadelphia hospitals and their EDs have voluntarily sought, and achieved, accreditation by the Joint Commission. This independent, not-for-profit organization certifies more than 17,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized as a symbol of quality and safety that reflects a hospital’s commitment to meeting certain performance standards. Every 18 months to three years, the Joint Commission sends surveyors, unannounced, to the hospitals it has accredited. The Joint Commission’s review of the hospital performance is comprehensive and exhaustive. Philadelphia hospitals are proud of having achieved and maintained this certification.

Beyond meeting these stringent licensing and certification requirements, ED physicians, nurses, and administrators, in their quest for excellence, review and adopt guidelines developed by highly respected organizations such as the American College of Emergency Physicians and the Emergency Nurses Association. In 2003, these organizations endorsed Triage Scale Standardization, stating that, based on expert consensus of currently available evidence, “quality of patient care would benefit from implementing a standardized emergency department triage scale and acuity categorization process.” Philadelphia hospitals have adopted this five-stage scale.

In addition to their EDs, eight of the City’s hospitals have trauma centers. These facilities must adhere to requirements and standards set forth by the Pennsylvania Trauma Systems Foundation. The average Pennsylvania trauma center spends $1.35 million a year on equipment, staff, training and education to meet the standard for compliance for accreditation.

Communities Served

Philadelphia’s 15 EDs serve the City’s population of nearly 1.5 million. Of these, nearly 500,000 are Medicaid (or Medical Assistance) eligible; about 450,000 are Medicare eligible. About 335,000 people have commercial insurance. Nearly 160,000 adults and children have no health insurance.

According to 2006 data, the City’s median household income is $33,229. Two thirds of all households earn less than $50,000. One quarter of Philadelphians and one-fifth of households live below the poverty line.

Philadelphia’s population is aging. Among the nation’s 10 largest cities, Philadelphia has the highest proportion of residents more than 65 years old. The racial and ethnic makeup of Philadelphia is also very diverse.

In 2008, Philadelphians went to City EDs nearly 900,000 times. For every 1,000 Philadelphians, hospitals provided care during more than 620 ED visits.

Array of Services and Resources

From cut fingers and ear aches to Level 1 traumas and full-scale disasters, the City’s network of emergency rooms and trauma facilities must be ready to care for anyone and anything. According to the American Hospital Association, a typical urban ED can expect to see, and must be prepared to treat, well over 1,500 conditions. Respiratory infections, viral infections, asthma, stomach pain, alcohol abuse, and pneumonia are among the most common conditions treated. Behavioral health visits are on the rise. Nationally, about 70 percent of all ED visits are emergent, urgent, or semi-urgent. About 15 percent are non-urgent and another 15 percent are uncategorized. According to the Centers for Disease Control and Prevention, recommended times to treatment range from within 15 minutes for the most emergent needs to 24 hours for non-urgent conditions.

In addition to this fundamental role of being ready and capable of treating virtually any health emergency, hospitals and their EDs must meet two other key needs. On the one hand, for many Philadelphians, EDs function as the access point for health care and even social services, providing basic primary care, chronic care, and other assistance. On the other hand, especially since the tragic events of 9-11, hospitals play a key role as first, or near-first, responders in case of large-scale accidents, natural disasters, epidemics, and terrorist actions.

To fulfill their mission of caring for all who come through their doors, hospital EDs have invested in innovative ways to provide the right care in the right setting at the right time. Most Philadelphia EDs have, or are creating, “fast track” or urgi-center type facilities within or near their EDs to provide the appropriate care for health needs judged less urgent or less complex during triage. This practice provides a more comfortable, less resource-intense treatment environment for non-critical health needs. At the same time, fast tracks preserve emergency staff and equipment for patients with more extreme emergencies. In effect, hospitals are providing primary care doctors’ offices inside their emergency rooms.

With more than 40 percent of Philadelphians un- or under-insured, these fast tracks are sorely needed. Nationwide, visits to the ED by Medicaid and uninsured patients are increasing twice as fast as visits by commercially insured patients. EDs care for more than twice the proportion of Medicaid and uninsured patients that physicians’ offices care for. As a result of our nation’s prolonged recession and jobless recovery, enrollment in Medicaid is accelerating. In fiscal year 2009, southeastern Pennsylvania enrollment grew nearly 10 percent – about three times the average annual rate for each of the previous four years.

Pennsylvania does not have public hospitals that receive direct financial support from government, such as exist in major metropolitan areas in other states. As a result, much of the responsibility for providing health care services to un- and under-insured Philadelphians falls on the City’s emergency departments.

In times of disaster, communities look to hospitals to mobilize resources to care for the ill and injured, provide food and shelter, and assist in coordinating relief and recovery efforts. Hospitals are investing in equipment, planning, and training to be prepared for natural disasters and chemical, biological, nuclear, or explosive events. As they upgrade and enlarge, always striving to improve, Philadelphia EDs are adding decontamination units and building surge capacity. In part through the work of DVHC, hospitals and EDs throughout the region work together to prepare for the possibility of a full-scale emergency, developing mutual aid agreements and common communications systems and engaging in training and practice exercises.

Challenges

In many ways hospitals, and especially EDs, are struggling to span the gaps in our fragmented health care system. Emergency departments in Philadelphia, the region, the state and the nation, face two key challenges:

• Demand for emergency care is rising while the number of emergency departments is decreasing.
• Many aspects of emergency care are underfunded.

Across the board, visits to emergency departments are on the increase, while the number of EDs is decreasing. From 1997 to 2007:

• In Philadelphia, ED visits increased nearly 25 percent while the number of EDs decreased by more than 40 percent.
• In the five-county region, visits increased nearly 25 percent; the number of EDs decreased by nearly a third.
• In Pennsylvania, visits increased nearly 25 percent; the number of EDs decreased by nearly a fifth.

Factors driving this growth in ED utilization include, as noted, the increase in patients with Medicaid or no insurance. Likewise, Philadelphia’s aging population increases ED volumes since older adults need and use far more health care than other age groups. Pennsylvania’s growing shortage of primary care physicians, including family practice, internal medicine, obstetrical, and pediatric doctors, is also of concern. Dual-career families struggling to make ends meet and unable to find timely, convenient primary care are all the more likely to turn to EDs.

The second challenge faced by hospital EDs is chronic underfunding. As safety nets for the un- and under-insured, EDs often provide care free of charge, or in the case of Medicaid, at below cost. Hospitals do their best to advise uninsured patients of their insurance options and assist them in the application process. Nevertheless, many emergency care services are not fully reimbursed. In addition, hospitals lose money on care provided to patients with Medicaid. On average Pennsylvania hospitals are reimbursed 82 percent of the cost of services provided to Medicaid patients. In other words, hospitals lose 18 cents on every dollar of care provided.

In addition to being underpaid for services, hospital EDs face a growing shortage of funding to support their “stand-by” role. In order to be prepared to treat many different conditions, EDs must maintain a wide range of special staff and equipment “on stand-by.” As part of their mission, hospitals subsidize these stand-by costs with payments from other types of care that are reimbursed more equitably.

These funding challenges contribute to the thin profit margins of Philadelphia hospitals. In fiscal year 2008, three out of four Philadelphia hospitals had negative total margins. In contrast, Pennsylvania ambulatory surgical centers on average enjoyed total margins of more than 26 percent. These facilities specialize in providing good-paying elective diagnostic and surgical care and cater to patients with commercial insurance – but depend upon hospital EDs to provide emergency care if complications develop.

Innovations in Emergency Care

Hospitals constantly strive to improve the health and health care of their communities, finding new ways to deploy their resources more effectively with the goal of providing the best possible health care for their patients. For hospital EDs, this has meant investing in innovative technology, programs, and services to develop the capacity to serve more patients and provide patient education and preventive health care to avoid unnecessary health emergencies. Such innovations include:

• Programs to help patients with chronic conditions better understand and manage their special health needs.
• Special efforts to connect patients to primary and outpatient care.
• Transition units that comfortably care for ED patients slated for hospital admission and free up ED resources for incoming patients.
• Health information technology to track patients and staff, monitor wait times, allow for online ordering of tests and procedures and results reporting, and provide access to medical histories.
• Participation in studies and improvement initiatives to improve ED operations and patient care.
• Interventions for victims of intentional violence, to provide the support and counseling necessary to protect themselves from future injuries.

Conclusion

The emergency departments of Philadelphia hospitals are committed to providing the best care possible for all who come through their doors. Thousands of physicians, nurses, and other health care professionals dedicate themselves to providing excellent, efficient emergency care 24 hours a day, every day of the year.

	Print This Document
	Email This Document