Palm WATCH

tives and fleribiiity are crucial if hospitals are going to be able to adapt and respond to local goals, population changes, and the ever-&anging landscape of new programs and technology. A cou- ple of Lave et d’s coswlusiw are warth emphasin@ (1) The main advantage of the global budget- ing is its simpli&Y and its ability to h%lp cxxltrol Goss. (2) This specific system is the product of a political environment that is quite different from the U.S. (3) To implement systems like the Ontario approach requires exten- sive consensus-building among all involved-no mean feat

F’inally, it should be pointed outthattomioromanagathe bud- get of globally funded institu- tionsrunstheriskofdestroying its main advantagef+simplicity and low mauagement costs--al- though the advantages of micro- management and microincen- tives have yet to be confirmed. For example, the average costs per patient in Canadhm hospitals are already less than in the U.S., so it catmot be assumed what the “true” impact of U.S.-style cost- containment measures will be, at least not,in Canada. To con&de, on a oautionary note, when revis- ing any health system, one must ask four other key questions: what benefits, who benefits, who deeides, and who pays. Global budget@ only deals with how much.-WDD

[Stern RS, Wtitnian JS, i&etein AM. !a8 8m8m8mcY d8rmrtnmt aa a p&way to ti&nGon fop poor and high-met patiemte. JAMA NM; iI6& -1

I t is virtually impossible to overestimate the importance of the hospital emergency

roomastheentrypointtothe health care system for the poor

anduninsuredinthiscountry. many inner-eity

ous studies have cited how emer- gency department admissione tendtohavelxighercostathanad- missions through other routes, even when controlbug for diagno- sis-related group (DRG). Iiow- ever, virtuaBy no investigations have shed light on what causes this phenomenon and, in particu- lar, on patient characteristics that could contribute to it.

Three dimensions represent the central features of this study’s analysis: (1) the social oharacteristics of the patient, in- cluding income and demograph- ica; (2) clinical characteristics in- cluding primary and secondary diagnosis, DRG, and severity of illness; and (3) resource charac- teristics such as payer, length of stay, and toti charges. Analysis of the components of these di- mensions was conducted to de- termine whether patients admit- ted through the emergency room differ from patients admitted through other routes and wheth- er there is an association between admission routes and use of re- souroes. The research was based on 20,039 patients admitted dur- ing a &month period to 5 hospi- talsinMassachusettsin1937.In addition to key information pro- vided by participating hospitals, the research team obtained de- mographic characteristics, sooio- economic status, and availability of a regular source of care through patient interviews.

Just over 50% (50.7%) of the 20,089 admissions occurred through the emergenoy depart- ment. These admissions ,differed significantly from ambulatory care patients admitted to the five hospitals in that they tended to be nonwhite, of lower socioeco- somic status, ol&r~ aad unmnr- ried. While Medicaid patients wereclWlymorehkelytoenter

the hoepital through the emer- ge&W department than kmred @&vi

PriwatfrlY

&md d%-mmtrat%d the great&St difference (i.e., a 3.1 times greater likelihood for admission through the emergency department). Re- sources used in emergency room admissions were clearly higher than in ambulatory admissions even after controlling for sever&y of illness: length of stay was 27% higher and charges were 13% greater.

The authors conclude that the profile of patients admitted through the emergenw depart- ments of the study hospitals mir- rors the classic indicators for a population facing health care ac- cess problems. The significant difference in costs related to this access problem occurs even when age, so&economic factom mver- ity of illness, and age are con- trolled. The authors suggest that the unplanned nature of these admissions, uncertain diagnosis, placement issues (espe&lly for medical patients), and lack of treatment management plans may all contribute to greater re- source use. Consequences for care include the potential for reduced access to emergency department services if hospitals believe they are financial liabilities. They also suggest the potential need for considering adjustments to hos- pital reimbursement formulas if they admit large numbers of pa- tients through their emergency departments.

This important report adds further credence to the argument that emergency department use is a key indicator of health care access problems. Moreover, it suggestswhyhospitalsfacingthis situation may experience diffi- culty in justifymg higher reim- bursement rates. That is, other factors more subdbe than severity >f illness, such as placement and Luabihty to plan for a patient ad- tnission or develop a treatment

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