The Affordable Care Act and Emergency Care

Mark McClelland, DNP, Brent Asplin, MD, MPH; Stephen K. Epstein, MD, MPP; Keith Eric Kocher, MD, MPH; Randy Pilgrim, MD; Jesse Pines, MD, MBA, MSCE; Elaine Judith Rabin, MD; Niels Kumar Rathlev, MD


Am J Public Health. 2014;104(10):e8-e10. 

In This Article

A Connected Rapid Diagnostic Center

The core competence of EDs is the ability to serve as a rapid diagnostic center with 24–7 access to high technology care and specialists.[23] This capacity can play a key supporting role for the medical home, particularly for populations with high-acuity illness. New payment models will also require EDs to play a greater role in care coordination, particularly for patients who do not require hospitalization. These expanded services will likely require expanded ED capacity and an expansion of units, such as clinical decision units.[24] Many EDs are also expanding social-work and case-management intervention programs for high-cost users; some of these programs have been successful in lowering hospital costs and improving outcomes.[25,26] There will be greater focus on hospital admission decisions themselves, which has historically been a process disconnected from outpatient primary care systems and community resources. Finding alternatives to hospital admissions by EDs may be one way of achieving significant cost savings.[27] Just one such alternative, widely used in Europe but facing payment challenges in the United States, is "Hospital at Home." This disruptive innovation, where home-based acute care substitutes for the traditional inpatient admission, has been shown to be well received by patients, effective, and less costly than comparable inpatient admissions.[28–31] Other innovations, such as post-ED follow-up clinics where patients are guaranteed access and ED call-back programs, may also extend the role of the ED beyond a single visit and provide an alternative to admission for some patients. Forward-thinking delivery organizations are already engaging their EDs to improve the efficiency of admission decisions. Payment reform based on episodes of illness and bundled payments may accelerate the development of these programs, as well as the alignment of hospital-based and non–hospital-based providers.

The ACA will have far-reaching effects on the way health care is designed and delivered. EDs are multifunctional units that can deliver great value at the interface between ambulatory and inpatient care. EDs have the potential to be at the center of many of these changes, but system-level engagement is needed to connect EDs with the wider outpatient care system and help the nation move to an integrated delivery across settings.