Hospitals Eliminate 1 in 4 U.S. Emergency Rooms in Past 20 Years

More than one in four U.S. emergency departments were closed in the past two decades, forcing the nation’s poor and elderly to seek care in fewer, more crowded facilities, researchers found.

The number of emergency rooms in metropolitan and suburban areas fell 27 percent to 1,779 in 2009 from 2,446 in 1990, according to research today in the Journal of the American Medical Association. During the study, 374 emergency departments were opened.

Departments most likely to close were in for-profit hospitals and facilities that serve high numbers of patients on Medicaid, the U.S. health plan for the poor, the researchers found. Closing an emergency room results in overcrowding at other hospitals, which can hurt patient care, said Renee Hsia, the study’s lead author.

“When people don’t have ERs in their neighborhood, it’s not like their emergency disappears,” Hsia, an assistant professor of emergency medicine at the University of California, San Francisco, and an emergency attending physician at San Francisco General Hospital, said in a telephone interview. “Emergency departments can’t pay for themselves, and it’s expensive care.”

Emergency rooms are required by federal law to treat all patients who need critical care regardless of whether they have insurance or the ability to pay.

Domino Effect

Closing a hospital emergency room “displaces tens of thousands of patients, many of them uninsured and low income, which leads to increased crowding at other emergency departments and can create a domino effect,” said Caroline Steinberg, vice president for trends analysis at the American Hospital Association in Washington.

While emergency rooms are being cut, demand for their services is rising. The number of emergency visits climbed to 127 million in 2009 from 89 million in 1991, according to the AHA.

Today’s study is the first to look at the risk factors behind emergency room closures, Hsia said. Researchers used American Hospital Association data on emergency rooms that closed from 1990 to 2009 and merged it with hospital and payer information from Medicare cost reports.

The closures “didn’t just happen in one part of the country,” Hsia said. Rather, they happened across the nation “in a very consistent way,” she said.

Health-Care Failure

The shutdown of emergency rooms represents a failure of the health-care financial system, Sandra Schneider, professor in the Department of Emergency Medicine at the University of Rochester Medical Center and president of the American College of Emergency Physicians, said in a telephone interview.

“The emergency care in this country is in crisis,” she said. “We’re crowded because we can’t get those patients into the hospital because, in many cases, the hospitals have cut down on the number of beds. We don’t anticipate that it will get any better.”

Steve Speil, senior vice president for health, finance and policy for the Federation of American Hospitals, a Washington-based trade group for investor-owned hospitals, said the study may not have captured what’s actually occurring because of the data used. If a for-profit hospital buys another, the owners might consolidate under one new provider number, making it appear that hospitals have closed, he said.

“I was disappointed in this study because the need for emergency departments and the overcrowding is, as they point out, a major problem,” he said in a telephone interview today. “This study is distorting the data and does not advance us toward a policy solution.”

Safety Net

Nassau University Medical Center in East Meadow, New York on Long Island is opening a new $36 million emergency department. The hospital, considered a safety-net facility because of the high number of Medicaid patients it treats, is hoping the new emergency department with additional private rooms will attract patients from nearby communities, said Anthony Boutin, chairman of the Department of Emergency Medicine.

“To stay competitive with other hospitals, we had to fix our front door, which is our emergency department,” Boutin said today in a telephone interview. The emergency department had about 73,000 visits last year.

Today’s study was funded in part by the U.S. National Institutes of Health and the Robert Wood Johnson Foundation Changes in Health Care Financing and Organization Initiative.

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