The Emergency Department Role in the US Healthcare Delivery Mechanism

The Emergency Department The Emergency Department Role in the US Healthcare Role in the US Healthcare

Delivery MechanismDelivery Mechanism

Carey D Chisholm, MDCarey D Chisholm, MD

Emergency Medicine & Combined Peds-EM Emergency Medicine & Combined Peds-EM Residency DirectorResidency Director

IUSM MS4 EM RotationIUSM MS4 EM Rotation

Carey D Chisholm, MD

No relevant financial relationships

Have you (or immediate Have you (or immediate family member) been a pt. in family member) been a pt. in the ER in the last 5 years?the ER in the last 5 years?

1 2 3

0% 0%0%

1.1. YesYes

2.2. NoNo

3.3. NeverNever

Which characterizes your impression of Which characterizes your impression of care rendered in the ER?care rendered in the ER?

1 2 3 4 5 6 7

0% 0% 0% 0%0%0%0%

1.1. Excessive wait timesExcessive wait times

2.2. ExpensiveExpensive

3.3. High medicolegal High medicolegal risksrisks

4.4. ImpersonalImpersonal

5.5. Mainly triageMainly triage

6.6. Poor privacyPoor privacy

7.7. SuperficialSuperficial

Which of these most accurately Which of these most accurately characterizes US ED care?characterizes US ED care?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Contributes 50% of total Contributes 50% of total health care expenditures health care expenditures in the USin the US

2.2. 50% of ED care is non-50% of ED care is non-urgent urgent

3.3. Most expensive care in Most expensive care in the USthe US

4.4. The majority of ED users The majority of ED users are insured are insured

5.5. All except DAll except D

National Center for Health Statistics (CDC-P), 2011

GoalsGoalsDiscuss unique features of the ED in the Discuss unique features of the ED in the US healthcare settingUS healthcare settingUnderstand who, how and why patients Understand who, how and why patients seek care in the EDseek care in the EDDiscuss Discuss ““quality indicatorsquality indicators”” of care in the of care in the EDEDDescribe the Describe the ““ED approachED approach”” to rendering to rendering care.care.3 pragmatic questions to make your 3 pragmatic questions to make your rotation go smoother.rotation go smoother.

Why the ED???? 1Why the ED???? 1

Why the ED??? 2Why the ED??? 2

Why the ED??Why the ED??

““True emergencyTrue emergency”” (how define non-emergency?) (how define non-emergency?)Lack of alternative accessLack of alternative access– Uninsured/No PCPUninsured/No PCP– No appt. at PCPNo appt. at PCP– AfterhoursAfterhours– Acute problemAcute problem

Access to technologyAccess to technologySent by PCPSent by PCPTravelersTravelersSocietal outcastsSocietal outcasts““Drug seekersDrug seekers””

What % of non-admitted ER pts What % of non-admitted ER pts are referred there by their PCP?are referred there by their PCP?

1 2 3 4 5

0% 0% 0%0%0%

1.1. 1%1%

2.2. 5%5%

3.3. 10%10%

4.4. 20%20%

5.5. 40%40%

CDC 2012

"I mean, people have access to "I mean, people have access to health care in America. … After all, health care in America. … After all,

you just go to an emergency room." you just go to an emergency room."

President GW Bush 2007President GW Bush 2007Rush says health care reform is Rush says health care reform is “insidious”, claims there is health care for “insidious”, claims there is health care for poor people: “it’s called the ER” Nov 2010poor people: “it’s called the ER” Nov 2010

How many EDs are there in the How many EDs are there in the US?US?

1 2 3 4 5

0% 0% 0%0%0%

1.1. 2,0002,000

2.2. 4,5004,500

3.3. 10,00010,000

4.4. 20,00020,000

5.5. 50,00050,000

National Center for Health Statistics (CDC-P), May 2010

How many patient visits occurred How many patient visits occurred in US EDs in 2009?in US EDs in 2009?

1 2 3 4 5 6

0% 0% 0%0%0%0%

1.1. 500,000500,000

2.2. 950,000950,000

3.3. 12 million12 million





Of 305 million US citizens, how Of 305 million US citizens, how many lack health insurance/year?many lack health insurance/year?

1 2 3 4 5

0% 0% 0%0%0%






Which demographic group contains Which demographic group contains the most (total) uninsured??the most (total) uninsured??

1 2 3 4 5

0% 0% 0%0%0%

1.1. AA women 18 – 35 yearsAA women 18 – 35 years

2.2. Caucasian men 18 – 35 Caucasian men 18 – 35 yearsyears

3.3. Latino men 18 – 35 Latino men 18 – 35 yearsyears

4.4. Undocumented Undocumented immigrantsimmigrants

5.5. Urban Children 2 – 16 Urban Children 2 – 16 yearsyears


Which of the following characterizes the Which of the following characterizes the one year % increase and avg. charge to one year % increase and avg. charge to

insure a family of 4 in 2011?insure a family of 4 in 2011?

1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%

1.1. 2%, $5k2%, $5k

2.2. 5% , $5k5% , $5k

3.3. 2%, $10k2%, $10k

4.4. 5%, $10k5%, $10k

5.5. 9%, $10k9%, $10k

6.6. 9%, $15k9%, $15k

7.7. 12%, $10k12%, $10k

8.8. 12%, $15k12%, $15k

Why the UninsuredWhy the Uninsured”” ED docs are altruistic?ED docs are altruistic?EMTALAEMTALAAny patient who "comes to the emergency department" Any patient who "comes to the emergency department" requesting "examination or treatment for a medical requesting "examination or treatment for a medical condition" must be provided with condition" must be provided with "an appropriate "an appropriate medical screening examination"medical screening examination" to determine if he to determine if he is suffering from an is suffering from an "emergency medical "emergency medical condition".condition". If he is, then the hospital is obligated to If he is, then the hospital is obligated to either provide him with treatment until he is stable or to either provide him with treatment until he is stable or to transfer him to another hospital in conformance with transfer him to another hospital in conformance with the statute's directives.the statute's directives.Another section [42 CFR 489.20(q)(1)] requires that the Another section [42 CFR 489.20(q)(1)] requires that the hospital post a conspicuous sign which notifies hospital post a conspicuous sign which notifies patients and visitors of the patients and visitors of the right to be examined right to be examined and to receive treatmentand to receive treatment. The sign must be in a . The sign must be in a form approved by the Secretary of Health and Human form approved by the Secretary of Health and Human ServicesServices

The cost of emergency care required by EMTALA is not The cost of emergency care required by EMTALA is not directly covered by the federal government. Because of this, directly covered by the federal government. Because of this, the law has been criticized by some as an unfunded the law has been criticized by some as an unfunded mandate.mandate.[4] Similarly, it has attracted controversy for its Similarly, it has attracted controversy for its impacts on hospitals, and in particular, for its possible impacts on hospitals, and in particular, for its possible contributions to an emergency medical system that is contributions to an emergency medical system that is "overburdened, underfunded and highly fragmented"."overburdened, underfunded and highly fragmented".[5]

More than half of all emergency room More than half of all emergency room care in the U.S. now goes care in the U.S. now goes uncompensated.uncompensated. Hospitals write off such care as Hospitals write off such care as charity or bad debt for tax purposes. Increasing financial charity or bad debt for tax purposes. Increasing financial pressures on hospitals in the period since EMTALA's pressures on hospitals in the period since EMTALA's passage have caused consolidations and closures, so the passage have caused consolidations and closures, so the number of emergency rooms is decreasing despite number of emergency rooms is decreasing despite increasing demand for emergency care.increasing demand for emergency care.[6] There is also There is also debate about the extent to which EMTALA has led to cost-debate about the extent to which EMTALA has led to cost-shifting and higher rates for insured or paying hospital shifting and higher rates for insured or paying hospital patients, thereby contributing to the high overall rate of patients, thereby contributing to the high overall rate of medical inflation in the U.S - wikipediamedical inflation in the U.S - wikipedia

How much EMTALA related care How much EMTALA related care does the avg. EM physician does the avg. EM physician

provide each yr?provide each yr?

1 2 3 4 5

0% 0% 0%0%0%

1.1. $5000$5000

2.2. $10,000$10,000

3.3. $25,000$25,000

4.4. $75,000$75,000

5.5. $125,000$125,000

AMA 2003

EMTALA EMTALA ““Unfunded MandateUnfunded Mandate””

AMA Study 2003AMA Study 2003– Avg ED physician renders $138,000/year in Avg ED physician renders $138,000/year in

uncompensated EMTALA related care.uncompensated EMTALA related care.

Surgery was #2Surgery was #2– $28,000/year$28,000/year– Avg. $25,000 across all other specialtiesAvg. $25,000 across all other specialties

“One-third of emergency physicians provide more than 30 hours of EMTALA-related care each week.”

ERs Provide the Bulk of Acute ERs Provide the Bulk of Acute

Care to Un-and-Under InsuredCare to Un-and-Under InsuredActive physicians

(597,430))

ER DocsPrimaryCare MDs Specialists

Acute visits by the uninsured (24 million))

Acute visits by –Medicaid or SCHIP (39 million)

Total acute visits(273 million))

Pitts et al. Health Affairs, Sept 2010

4%

50%

65%

Not just the uninsuredNot just the uninsured

MajorityMajority of users have medical insurance of users have medical insurance

Lack of access to their own PMD Lack of access to their own PMD appointmentsappointments

Perceived emergency conditionPerceived emergency condition

Access to after-hours care Access to after-hours care

No co-payment at time of delivery of careNo co-payment at time of delivery of care

““One-stop shoppingOne-stop shopping””

Other Other ““Unique Features of the EDUnique Features of the ED

24 – 7 24 – 7

For the For the MAJORITYMAJORITY of hours for every day of of hours for every day of every week in every year, the ED is the every week in every year, the ED is the ONLYONLY health care available to Americans. health care available to Americans.

Want to live here??

Community Healthcare Community Healthcare ““Nerve CenterNerve Center””

Referral from PMDs for access to Referral from PMDs for access to specialized treatments or diagnostic specialized treatments or diagnostic tests.tests.Access to lab, imaging after hours.Access to lab, imaging after hours.““SpecializedSpecialized”” acute care features acute care features– SANESANE– Med Tox / PCCMed Tox / PCC– CVA/MICVA/MI– TraumaTrauma– Environmental Environmental

Mass Gathering – Mass CasualtyMass Gathering – Mass Casualty

““The only The only ‘‘infinitely expansibleinfinitely expansible’’ component of the health care systemcomponent of the health care system””

ED Crowding

According to the US Govt., what % According to the US Govt., what % of ED visits are “unnecessary”?of ED visits are “unnecessary”?

1 2 3 4 5

0% 0% 0%0%0%

1.1. 55

2.2. 1010

3.3. 2525

4.4. 5555

5.5. 8080

How did they arrive at that figure?How did they arrive at that figure?

Discharge diagnosisDischarge diagnosis

Methodology flawed?Methodology flawed?

Pts present with a SYMPTOM complex, Pts present with a SYMPTOM complex, NOT a diagnosis!NOT a diagnosis!

ThatThat’’s why yous why you’’re going to LOVE this re going to LOVE this month!!!!month!!!!

YOU get to formulate a diff dx and plan for YOU get to formulate a diff dx and plan for YOUR patient.YOUR patient.

What % of ED Visits are What % of ED Visits are nonurgent?nonurgent?

1 2 3 4 5

0% 0% 0%0%0%

1.1. 8 - 108 - 10

2.2. 18 - 2018 - 20

3.3. 30 - 3330 - 33

4.4. 45 - 5045 - 50

5.5. 60 - 6660 - 66


Which of the following discharge Dx Which of the following discharge Dx does NOT require EM services?does NOT require EM services?

1 2 3 4 5 6 7 8

0% 0% 0% 0%0%0%0%0%

WA State Medicaid services, 2011

1.1. Acute tonsillitisAcute tonsillitis

2.2. BronchopneumoniaBronchopneumonia

3.3. ErysipilasErysipilas

4.4. Herpes zosterHerpes zoster

5.5. Missed abortionMissed abortion

6.6. Salmonella enteritisSalmonella enteritis

7.7. Scarlet feverScarlet fever

8.8. All of the aboveAll of the above

Which group is most likely to Which group is most likely to have a non-urgent visit to the have a non-urgent visit to the

ED?ED?

1 2 3 4 5

0% 0% 0%0%0%


1.1. InsuredInsured

2.2. MedicaidMedicaid


4.4. UninsuredUninsured

5.5. All have similar All have similar ratesrates

Cost of care in the ED?Cost of care in the ED? Avg charges ER visit $383 (1996), $903 (2008).Avg charges ER visit $383 (1996), $903 (2008).Avg PCP office visit costs $60 (2001), $199 (2008). Avg PCP office visit costs $60 (2001), $199 (2008). According to the National Center for Health Statistics, 55 According to the National Center for Health Statistics, 55 percent of the 90 million visits to EDs in the United States percent of the 90 million visits to EDs in the United States in 1996 were unnecessaryin 1996 were unnecessary (PAIN NOT a (PAIN NOT a ““necessarynecessary””))““Emergency room treatment for non-emergency medical Emergency room treatment for non-emergency medical conditions is a major contributor to the rising cost of conditions is a major contributor to the rising cost of health carehealth care””“High emergency room (ER) utilization is a considerable concern for the increasing cost of health care. Frequent and inappropriate use of hospital ERs is extremely costly and care could be provided in a less expensive setting.” WSHA

Cost of ED careCost of ED care

““Average ED visitAverage ED visit”” c/w c/w ““Avg office visitAvg office visit””??

How define How define ““unnecessaryunnecessary””??

Cost shifting and McD model.Cost shifting and McD model.

Incremental visit analysisIncremental visit analysis

Medical Econ 101Medical Econ 101

Difference between Difference between ““costscosts”” & & ““chargescharges””..CT scan exampleCT scan example– $800$800

Pharyngitis examplePharyngitis example– ““costs” vs patient chargescosts” vs patient charges

What % of total US Govt healthcare What % of total US Govt healthcare spending goes to ED care?spending goes to ED care?

0%0%0%0%0%

1 2 3 4 5

1.1. 2 – 32 – 3

2.2. 10 – 1210 – 12

3.3. 15 – 1715 – 17

4.4. 20 – 2520 – 25

5.5. 40-5040-50

In fact, the US Govt spends In fact, the US Govt spends more each year to have more each year to have

Cardiologists over-read EKGs Cardiologists over-read EKGs for for MedicareMedicare beneficiaries beneficiaries

alone…..alone…..

2% 2%

CHARGES (EMTC)CHARGES (EMTC)

a.a. CBCCBC

b.b. BMPBMP

c.c. LIPASELIPASE

d.d. APAPAPAP

e.e. UPTUPT

f.f. TROPONINTROPONIN

g.g. UDSUDS

1.1. $30$30

2.2. $50$50

3.3. $75$75

4.4. $100$100

5.5. $125$125

6.6. $200$200

7.7. $250$250

8.8. $600$600

CHARGES (EMTC)CHARGES (EMTC)

CBCCBC

BMPBMP

LIPASELIPASE

APAPAPAP

UPTUPT

TROPONINTROPONIN

UDSUDS

1.1. $30$30

2.2. $50$50

3.3. $75$75

4.4. $100$100

5.5. $125$125

6.6. $200$200

7.7. $250$250

8.8. $600$600

What is the most frequent Sx What is the most frequent Sx complex presenting to the complex presenting to the

ED?ED?

……Put on your Gowns…Put on your Gowns…How to define How to define ““qualityquality”” ED care? ED care?

• TimeTime• Friendliness Friendliness • CommunicationCommunication• Address concernsAddress concerns• Meet expectationsMeet expectations• CleanlinessCleanliness• Privacy & confidentialityPrivacy & confidentiality• Bill for servicesBill for services

Which is the single most impt Which is the single most impt determinant of satisfaction?determinant of satisfaction?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Agenda/expectations Agenda/expectations are metare met

2.2. Bill for the visitBill for the visit

3.3. Communication Communication about the treatmentabout the treatment

4.4. Friendliness of the Friendliness of the staffstaff

5.5. TimeTime

And the Winner is And the Winner is

HypothesisHypothesis

The ED is the FF model in the health care The ED is the FF model in the health care industry … Fast and Friendlyindustry … Fast and FriendlyBut wait … youBut wait … you’’ve got a very bad ve got a very bad ““stomach flustomach flu”” …. ….And before pts. Became And before pts. Became ““customerscustomers”” … …

The ED as the The ED as the ““Safety NetSafety Net””

Fixation on time!!!!Fixation on time!!!!

ED Approach to providing careED Approach to providing care

FOCUSed care Hx, PE, Dx, Tx, DispoFOCUSed care Hx, PE, Dx, Tx, Dispo

– OK OK NOTNOT to do the to do the ““complete Hx and PEcomplete Hx and PE””

ROWCS instead of BayeROWCS instead of Baye’’s Theorums Theorum

– One shot approachOne shot approach

Data gathering coincides with Tx and DxData gathering coincides with Tx and Dx

Definitive answer often lacking at end of Definitive answer often lacking at end of encounterencounter

– Assure what they donAssure what they don’’t havet have

Time issues: Recall most Time issues: Recall most frequent CCfrequent CC

Alleviate pain and distressing SxAlleviate pain and distressing SxAssure more serious medical condition Assure more serious medical condition doesn'tdoesn't’’t existt existDecrease further morbidity by earlier Decrease further morbidity by earlier interventioninterventionWe fixate on waiting room timesWe fixate on waiting room times““The sickest patient in the ED is the one The sickest patient in the ED is the one waiting to be seen nextwaiting to be seen next””

The The ““3 Questions3 Questions””

What are you concerned your symptoms What are you concerned your symptoms may be caused by?may be caused by?

What are you hoping that I can do for What are you hoping that I can do for you today here in the ER?you today here in the ER?

What changed to make you decide to What changed to make you decide to come to the ED right now? come to the ED right now?

Have you had formal education Have you had formal education about safe patient trade-off?about safe patient trade-off?

1 2 3 4 5 6

17% 17% 17%17%17%17%1.1. Yes extensive (over 2 Yes extensive (over 2

hours)hours)

2.2. Yes, 1-2 hoursYes, 1-2 hours

3.3. Yes, mentioned in Yes, mentioned in passing in lecturepassing in lecture

4.4. Yes, but informal on Yes, but informal on the flythe fly

5.5. Yes, self study onlyYes, self study only

6.6. Not yetNot yet

Patient Change-OverPatient Change-Over

Under 10% of US MS grads in 2008 had Under 10% of US MS grads in 2008 had such education.such education.

MAJOR area for medical error, malpractice MAJOR area for medical error, malpractice risk, and patient inconveniencerisk, and patient inconvenience

Goals of ED ChangeoverGoals of ED Changeover

Presenting problemPresenting problem

ED Management Plan/ED CareED Management Plan/ED Care

Labs Ordered/ResultsLabs Ordered/Results

Disposition PlanDisposition Plan

Consultants ContactedConsultants Contacted

Follow up PlanFollow up Plan

Outstanding IssuesOutstanding Issues

““Fresh eyesFresh eyes””

Ye et al, Handover in the Emergency Department: Deficiencies and adverse effects. Emergency Medicine Australasia (2007) 19, 433–441

What are we doing?What are we doing?

Changeover SheetChangeover Sheet

Changeover SheetChangeover Sheet

Optimal UsageOptimal Usage1)1) Give empty sheet to oncoming studentGive empty sheet to oncoming student2)2) Oncoming student fills out sheetOncoming student fills out sheet3)3) Present patients with Present patients with ““most important firstmost important first””

philosophyphilosophy4)4) Changeover all patients (including admitted)Changeover all patients (including admitted)5)5) Introduce oncoming student to the Introduce oncoming student to the

supervising faculty with plan synopsissupervising faculty with plan synopsis6)6) Introduce oncoming student to patient/family Introduce oncoming student to patient/family

and ask if they have any further questions.and ask if they have any further questions.

SummarySummary

Undifferentiated pt populationUndifferentiated pt populationSx, not Dx. Always address SxSx, not Dx. Always address SxEDs have a unique place in US healthcareEDs have a unique place in US healthcare– Only 24-7 optionOnly 24-7 option– Dx and Tx Dx and Tx ““nerve centersnerve centers””– Incremental cost for each additional pt is lowIncremental cost for each additional pt is low– Medicare pts are sickMedicare pts are sick– Medicaid use higher than other groups Medicaid use higher than other groups – Uninsured have high utilization rates due to lack Uninsured have high utilization rates due to lack

of alternative accessof alternative access

SummarySummary

Unique ED Unique ED ““approachapproach””– FOCUS vs HolisticFOCUS vs Holistic– ““Single ShotSingle Shot”” to get it right to get it right– ROWCSROWCS– Fixation on timeFixation on time

Patients Patients ““at riskat risk”” until under physician care until under physician care

Address uncomfortable SxAddress uncomfortable Sx

Our Our ‘‘customerscustomers’’ expect prompt care expect prompt care

– Clarify the Clarify the ““3 Questions3 Questions””– SAFE transitions of careSAFE transitions of care

When is CC not true problem?When is CC not true problem?

1 2 3 4 5

20% 20% 20%20%20%

1.1. SexSex

2.2. Domestic violenceDomestic violence

3.3. PsychPsych

4.4. MalingeringMalingering

5.5. All of aboveAll of above

120 Million ED Visits (2006)120 Million ED Visits (2006)

Private Private InsuranceInsurance

34.6 %34.6 %

Medicaid Medicaid

21.6%21.6%

MedicareMedicare

20.1%20.1%

UninsuredUninsured

17.7%17.7%

38% 90.5%

88.2%

93.2%

50% of total ED admissions are Medicare

OverallInsured Uninsured

Why the Uninsured?Why the Uninsured?

How many uninsured US citizens?How many uninsured US citizens?

Is that number growing or decreasing?Is that number growing or decreasing?

How many ED visits were there in 2007?How many ED visits were there in 2007?

How many EDs in the US?How many EDs in the US?

Are those numbers growing or decreasing?Are those numbers growing or decreasing?

Who are the uninsured?Who are the uninsured?

ED Demographics ED Demographics Number of visits: 119.2 million (90 million in 1993)Number of visits: 119.2 million (90 million in 1993) Number of injury-related visits: 42.4 millionNumber of injury-related visits: 42.4 million Number of visits per 100 persons: 40.5Number of visits per 100 persons: 40.5 Most commonly diagnosed condition: injury and Most commonly diagnosed condition: injury and poisoningpoisoning Percent of visits with patient seen in fewer than 15 Percent of visits with patient seen in fewer than 15 minutes: 21.9minutes: 21.9 Median time spent in emergency department: 2.6 hoursMedian time spent in emergency department: 2.6 hours Percent of visits resulting in hospital admission: 15.4Percent of visits resulting in hospital admission: 15.4 Percent of visits resulting in transfer to higher level or Percent of visits resulting in transfer to higher level or specialized care needed: 1.9specialized care needed: 1.9

Source: Source: National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary, Tables 1, 10, 11, 21, 25

The UninsuredThe Uninsured

47 million US citizens uninsured (not UDI47 million US citizens uninsured (not UDI’’s)s)– 40 million Medicare 40 million Medicare – 38 million Medicaid38 million Medicaid– 202 million priv. insurer202 million priv. insurer

~ 4300 EDs, 10% drop over past decade~ 4300 EDs, 10% drop over past decade

Young, Caucasian and maleYoung, Caucasian and male– If an ethnic minority, more likely to be under-If an ethnic minority, more likely to be under-

unisuredunisured

How many EDs are there in the How many EDs are there in the US?US?

1 2 3 4 5

0% 0% 0%0%0%

1.1. 2,0002,000

2.2. 4,5004,500

3.3. 10,00010,000

4.4. 20,00020,000

5.5. 50,00050,000

How many patient visits occurred How many patient visits occurred in US EDs in 2008in US EDs in 2008

1 2 3 4 5

0% 0% 0%0%0%

1.1. 250,000250,000

2.2. 500,000500,000




Which of these most accurately Which of these most accurately characterizes US ED care?characterizes US ED care?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Contributes significantly Contributes significantly to the total health care to the total health care expenditures in the USexpenditures in the US

2.2. Most ED care is non-Most ED care is non-urgent urgent

3.3. Most expensive care in Most expensive care in the USthe US

4.4. The majority of ED users The majority of ED users are insured are insured

5.5. All of the aboveAll of the above

According to the US Govt., what According to the US Govt., what % of ED visits are “unnecessary”% of ED visits are “unnecessary”

0%0%0%0%0%

1 2 3 4 5

1.1. 55

2.2. 1010

3.3. 2525

4.4. 5555

5.5. 8080

Which demographic group constitutes Which demographic group constitutes the largest segment (total numbers) of the largest segment (total numbers) of

the uninsured in the US?the uninsured in the US?

1 2 3 4 5

0% 0% 0%0%0%

1.1. AA women 18 – 35 AA women 18 – 35 yearsyears

2.2. Caucasian Men 18 – Caucasian Men 18 – 35 years35 years

3.3. Latino men 18 – 35 Latino men 18 – 35 yearsyears


5.5. Urban Children 2 – Urban Children 2 – 16 years16 years

Of 305 million US citizens, how many Of 305 million US citizens, how many lack health insurance in any given year?lack health insurance in any given year?

1 2 3 4 5

0% 0% 0%0%0%






2 – 3 %2 – 3 %

What is the single most impt What is the single most impt determinant of lower ED use?determinant of lower ED use?

a. b. c. d. e.

0% 0% 0%0%0%

a.a. CaucasianCaucasian

b.b. Higher family Higher family incomeincome

c.c. Insurance statusInsurance status

d.d. Younger ageYounger age

e.e. A & CA & C


The Emergency Department Role in the US Healthcare Delivery Mechanism

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