In 2006, the Institute of Medicine (IOM) Committee on the Future of Emergency Care in the United States Health System published three reports.1–3
These reports described the emergency care system as stressed, overcrowded, and unable to appropriately respond to patient care demands. In 2009, the American College of Emergency Physicians (ACEP) released a National Report Card on the State of Emergency Medicine that reinforced these findings, with an overall grade for emergency care in America a dismal “C minus.”4
The IOM reports suggest that there is significant fragmentation of the emergency care system with poor coordination, inefficient use of resources, and because of these issues, suboptimal patient outcomes. The IOM recommended the development of “regionalized, coordinated, and accountable emergency care systems throughout the country.”1
The word “regionalized” was used as a cornerstone of a vision for a new emergency care system with the following value proposition:
“Because not all hospitals within a community have the personnel and resources to support the delivery of high-level emergency care, critically ill and injured patients should be directed specifically to those facilities with such capabilities. That is the goal of regionalization.”1
In 2009, however, the IOM’s regionalization workshop made some important clarifications to this definition, distinguishing regionalization and centralization.5
“Centralization” suggests the delivery of patients to an “expert” emergency care hospital, whereas “regionalization” simply emphasizes that patients receive appropriate care for their condition. Regionalization involves not only moving patients
between geographically proximate facilities, but may also include moving expertise
(cognitive skills) and at times, moving technology
or other resources to certain patients (e.g., telemedicine, telephone consultation). The latter concepts offer the potential to reduce both expenditures and risks, without incurring the cost of a physical transfer. Through a combination of geographic- and knowledge-based regionalization, patients may benefit from the resources of centers with more experience (i.e., higher volumes of specific conditions), which may in turn improve outcomes.6
The IOM describes attributes of quality health care as “patient-centered, safe, effective, efficient, timely, and equitable.”1
From a public health perspective, an effective emergency care system will 1) optimize access to emergency care, 2) deliver quality care, and 3) effectively allocate resources at a sustainable system-level cost.7–10
The effects of spiraling costs of administrative aspects of health care in the U.S. have been well documented.11,12
True regionalization, or the creation of integrated networks across the entire health care continuum, can decrease costs as well as improve patient outcomes.13,14
In our current system, administrative structures are created with certain boundaries in place. Examples may include: 1) hospital or facility boundaries, affecting clinical privileges, accreditation, and quality measures; 2) state lines, creating boundaries around professional licensure; 3) health insurance networks, affecting payment and coverage for participants; 4) medical malpractice systems, with issues of coverage limits, policy structures, number and size of limits available, and hospital acceptance of coverage; and 5) quality reporting and accreditation systems.
Regionalization efforts must consider how to overcome barriers within our current system. Forming affiliations across these boundaries will often invoke changes that permit the reduction or elimination of current boundaries.
This article is a product of a working group on administrative challenges from the 2010 Academic Emergency Medicine consensus conference “Beyond Regionalization: Integrated Networks of Care.” We provide a brief history of some administrative challenges to regionalization of emergency care services, and discuss these challenges through the lens of reimbursement structures, medical-legal and risk considerations, quality reporting, and legal/regulatory systems. We suggest a research agenda that involves studying “natural experiments” with changes in emergency care systems, and implementing demonstration projects to improve the delivery of emergency care through improving patient outcomes for populations that will benefit from a newly designed emergency care delivery system.
History of regionalization in the United States
Regional networks first developed in the 1950s around trauma, and several decades later also around acute myocardial infarction (AMI) and stroke.15
These networks were focused on prehospital care – bringing the patient to an expert hospital by ambulance. This disease-oriented model of regionalization has not progressed significantly since then. Current regionalization efforts still surround conditions such as trauma, AMI, stroke, cardiac arrest (including therapeutic hypothermia), and sepsis,16–23
as well as certain services such as burn and critical care.24,25
Many systems involve prehospital and hospital care, through accredited centers of excellence (such as the trauma system). However, many of the networks of hospitals that treat these seemingly “regionalized” conditions are themselves fragmented and not truly integrated. Often, hospitals must work with a variety of partners, each of which may have individualized, disease-specific data collection and reporting requirements.
Beyond these conditions and a general push for public health preparedness,26–29
there has been little development in creating truly integrated networks, despite a growing awareness of the need to reduce redundancy and leverage resources optimally.30
During the 1990s, the anticipation of health reform and the pressures of managed care pushed hospitals31
to form systems through mergers and acquisitions. By 2000, 57% of private, acute care hospitals were part of hospital systems.32
This trend peaked around 2000 and began to fade shortly after, as hospitals’ initial financial goals were not realized and the pressures of capitation and health reform began to fade.33
However, many hospitals remain in systems, ranging from fully integrated delivery systems such as Kaiser, to looser affiliations such as Catholic Healthcare, and Hospital Corporation of America (HCA).
The primary factors limiting integration of emergency care relate to the absence of explicit system-level objectives, a lack of adequate funding or effective mechanisms of resource deployment, regional and health system variability, competitive factors, challenges in partnering with hospitals and prehospital systems, and administrative systems designed around functional silos, rather than integrated systems.5
Hospitals may also resist integration due to the loss of revenue streams for services that have high margins, such as interventional cardiology services.
Current models may allow for research into regionalization’s effects on the medical-legal environment and patient outcomes. Existing microcosms may serve as a laboratory for assessing what is likely to occur when regionalization is attempted on a larger scale. Four examples of successful regionalization projects were listed in the IOM report - the Maryland Emergency Medical Services (EMS) and Trauma System; Austin/Travis County, Texas; Palm Beach County, Florida; and San Diego County, California – but certainly many more exist.
New research must identify administrative systems and processes that support quality care, reduce risk, improve outcomes, drive system efficiencies, and allow cost-effective deployment of both economic and workforce resources. Even now, in a relatively non-integrated emergency care system, there are insufficient data to guide decision-making, system development, and resource deployment. Efforts to regionalize emergency care are expected to exacerbate current issues and create new challenges. Since the process of integrating systems will merge previously segregated, competitive, or even conflicting elements, it is critical to evaluate both current and proposed systems to ensure that optimal and sustainable patient care benefit is achieved.