Syndromic Surveillance: Insights into Healthcare Policy

Health Monitoring Systems is discovering that syndromic surveillance can also provide a rich source of information for public policy. Recently an American College of Emergency Physicians (ACEP) study found that ER physicians believe they are busier now than they were before implementation of the Affordable Care Act’s individual mandate. The study was covered in USA Today, giving it national exposure. We read the article with great interest, wondering if the data we’d collected supported the physicians’ perceptions.

So we peeked at the data collected in EpiCenter, comparing the same ERs reporting quarter-by-quarter from California to New Jersey.   That data shows that the ACEP survey was indeed correct; most facilities had more visits after the inception of the individual mandate than before.   But—and this is significant—for most facilities we looked at, there were fewer visits than in 2012.  So, why the belief that more people were coming into the ER? And what does the ACA have to do with the perceived increase?

We reached out to the author of the USA Today article, healthcare reporter Laura Ungar, to learn more about the policy implications of what ACEP’s respondents believe to be going on in ERs across the country.  Ms. Ungar explained that ACEP doesn’t have recent data related to physicians’ perceptions.
And that too is significant.  Public health departments operating syndromic surveillance systems have unique insight into healthcare utilization—insights not available elsewhere.

The peek at our data showed that from 2014 to 2015, out of 324 ERs that reported consistently in that period, 254 (78%) saw an increase in visits. By contrast, from 2012 to 2015 only 42.7% (117 of 274) of ERs had increased visits. Variation like that seems to indicate something is happening beyond the ACA’s individual mandate, which took effect on January 1, 2014.

That said, the effect of the Affordable Care Act on emergency departments is a real concern.  The promise of increased health insurance coverage is that emergency department usage for non-urgent visits will decline.  The theory goes that the uninsured population uses the emergency department as a surrogate for a primary care physician.  But for this promise to be fulfilled, the uninsured  —who live mainly in lower-income urban or rural areas with poor access to healthcare options — need access to more healthcare options.   That won’t happen overnight.

A deeper look at emergency department visits shows that the ACA’s individual mandate and the expansion of Medicaid may not be the only factors affecting ER visits and physician perceptions:

• Through the 2000s, a long-term trend in ER visits resulted in an increase of over 35% from 2000 to 2010.
• At the same time, the number of ERs decreased by nearly 10%.
• Urgent care centers, which can be a substitute for ERs, have multiplied: from none in the 1980s, there are now some 9,000 facilities in the United States, about twice the number of hospitals.
• The Oregon Study [http://www.nber.org/oregon/] showed that the newly insured Medicaid patients used emergency departments at a rate 40% higher than average.
• For the four years after the 2008 economic downturn, healthcare spending was at its lowest level in five decades; this was due to changes in the economy, not the ACA.
• Part of the ARRA, Meaningful Use requirements ushered in the era of EMR. The results are an increase in non-patient-related administrative tasks, making physicians even busier.

There’s no simple answer to the complex problem of ER utilization. But our data does indicate that the individual mandate in the Affordable Care Act can’t be the primary cause of rising visits by 2015.

All of this proves it’s time to rethink the role of syndromic surveillance: It’s not just a monitoring tool, but also a platform upon which the public health community can build healthcare policy.  The ACEP survey demonstrates just such an occasion.  ER physicians are concerned with the impact of the ACA on patient visits, but other factors confound their ability to understand what is affecting ER utilization.

Public health syndromic surveillance infrastructure can help address these policy concerns. No one else is as well equipped to tackle this challenging problem.