David White, MBA
Vice President and Director of Analytics
Huddy HealthCare Solutions, LLC

This is one of a series of articles by Huddy HealthCare Solution’s experts on ED analytics, planning and design. Each article offers insights to you as an ED physician leader on how to position your emergency department for architectural design success.

More than Just Population Numbers
Designing a new ED will push you to look to the future. Understanding where future Emergency Department (ED) volumes may be headed can be influenced by several different variables – impact on ED visits due to the Affordable Care Act (ACA), potential changes in the ACA, or other legislative actions. Other impacts may be due to future diversion of lower acuity (ESI 4s and 5s) to alternate care settings (other than the ED), population and demographic changes in key service areas, impact of new freestanding EDs in or around key service areas, and potential other actions taken by competitors or even your own health system. Future visits to your Emergency Department can be quantified through the analytics of three key factors:

  1. Local population and demographic trends
  2. Future ED use rates (i.e. number of ED visits per 1000 population) including estimated impacts of healthcare reform that are applicable to your service area(s)
  3. ED market share for your defined service area (including all future impacts of diversion strategies or competition)

In addition to those key factors, there are five other key issues that you need to consider when projecting your future ED volumes.

1. Defining Service Area
Identifying what your true Service Area is for your ED is one of the most important factors in helping to determine where future volumes may be heading. One of the biggest mistakes I’ve seen is assuming your Service Area to be defined by a pre-defined geographic location such as a surrounding three- county area or a pre-determined radius of (for example) 25 miles from the hospital. It is much more valuable to determine where your visits are coming from by zip code and then identify which zip codes represent ~85% of your total visits. This is typically an area of 25-30 zip codes in rural areas and 10-15 zip codes in urban areas. Although you may be getting visits from up to 1,000 or even 1,500 different zip codes in a given year, it is this “core group” of zip codes that will be driving future volumes. The maps below show an example of a ~60,000 visit ED – over 1,540 different zip codes were represented (larger national map) but over 90% of the total visits came from a subset of 25 zip codes (smaller service area map). Focusing your analytics on your “core group” of zip codes will be a key to determining a successful volume projection.

03_Huddy_Future ED Volumes_1


2. Impact of an Aging Population03_Huddy_Future ED Volumes_2
Although it is definitely important to understand the trends of total population, it is more important to understand the trends for the senior (65+ years old) population and especially the 75+ population. The 75+ population utilizes the Emergency Department about 150% more frequently that the under 75 population (ED Use Rate of 644 for 75+ compared to 421 for under 75+ population).


3. Legislative Impacts
Legislative impacts can have a tremendous impact on ED Utilization. The Affordable Care Act (ACA) that was enacted in January 2014 were projected to have significant impact on the utilization of emergency department services. One of the major goals of the ACA was to expand public and private insurance coverage to help reduce the number of uninsured people, which by 2012 was hovering around 48 million people, or 15.7% of the US population2. One of the earliest studies that looked at ED visits and the impact of an expanded Medicaid population showed that ED visits increased for those with Medicaid coverage compared to their uninsured colleagues. The study was performed in Oregon and showed that those who gained Medicaid coverage made 40% more visits to the emergency department compared to those who remained uninsured, and this pattern held true for most of the demographic segments and types of visits3. In 2014 the national ED Use Rate (ED Visits per 1000 people) was 427.6. The latest figures from the CDC show that by 2016 the use rate had increased to 441.2 so it appears that, at least in the short term, the ACA has not had the impact on decreasing ED visits as some had projected.

4. Utilization and ED Visit Types
As mentioned previously, along with an aging population comes not only an increase in ED Volumes but an increase in patient acuity, and in turn, an increase in admission rates. The increased admission rates may mean more “holding” or “boarding” of patients due to limited access to inpatient beds. Once you add in the initiative (that many organizations are focusing on) of shifting non-urgent patient acuities to lower cost settings (urgent care, primary care, telemedicine, or home health) it means that the future ED will be treating much sicker patients. This trend impacts ED length of stay times (and thus capacity) due to rising admission percentages, and higher utilization of ancillary studies. In fact, the projected increase of ED admission rates will likely impact ED capacity much more than just increasing in overall volume in the coming years.

5. Alternatives to the ED: Urgent Care, Freestanding ED, Retail Clinics, Telemedicine
Most organizations have been attempting to shift the care of non-urgent patients out of the ED with other alternatives. Certainly, urgent care has been offered as one opportunity for that shift. However, Huddy HealthCare’s experience has shown that urgent care is more of a substitute for unscheduled primary care visits as opposed to true emergency care. That experience, combined with the fact that the majority of urgent care centers require a co-pay upfront (unlike the ED) means that a large segment of the population will still would prefer to visit the ED. Freestanding EDs offer a much better alternative for siphoning off the ESI 4s and 5s as well as a good percentage of ESI 3s. The challenge with the Freestanding EDs is that these are often located in geographical areas that have excellent payor mixes (and usually have lower ED utilization rates due to increased access to care). So, this may not have much of an impact on the ED ‘Frequent Fliers’ (patients that have visited an Emergency Department four or more times in a given year). Retail Clinics (located in a Walgreens, CVS or Walmart) were another option that a few years back were thought to help shift some non-urgent visits out of the ED but seem to have similar results to urgent care clinics in that they also cater to more of a primary care substitute. Finally, telemedicine (video triage) may be a true pioneer to help alleviate ED overcrowding especially with the younger demographic that have grown up in the age of the internet, cell phones, and FaceTime… but that will take some time. The senior population is still somewhat resistant to that technology and will be the biggest driver of the change in ED visits over the next decade.

More Information
For more information on the analytics associated with future ED utilization and patient volumes, please contact Huddy HealthCare Solutions or visit our website at www.huddyhealthcare.com

If you are interested in other articles on ED analytics, planning or design, please contact Huddy HealthCare Solutions at j.huddy@huddyhealthcare.com

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