Impact of policy changes on emergency department use by Medicaid enrollees in Oregon

Insurance instability and use of emergency and office-based care after gaining coverage: An observational cohort study

Background

The Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced.

Methods

Our study draws from the 2013–14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1–11 months, ≥12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group.

Results

Being uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, p<0.01) and a 47% increase in office visits (1.10 visits, p<0.01), driven by those gaining public coverage. We found no evidence of substitution across settings in the short term, often a stated goal of expansion.

Conclusion

The long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.

Factors associated with inappropriate attendances at the emergency department of a tertiary hospital in Singapore

INTRODUCTION

Inappropriate attendances (IAs) at emergency departments (ED) are contributed by patients with mild or moderate medical conditions that can be effectively managed by primary care physicians. IAs strain limited ED resources and have an adverse impact on efficiency. This study aimed to identify factors associated with IA at the ED of a tertiary hospital in Singapore.

METHODS

We conducted a retrospective cohort study of all eligible visits to the aforementioned ED between 1 January 2015 and 31 December 2015. The appropriateness of each attendance was estimated using criteria based on investigations or procedures that were performed on the attendee and the discharge type of that attendance. IAs were then compared against appropriate attendances in these areas: attendee demographics; referral source; time of ED visit; proximity to ED and 24-hour general practitioner clinics; and history of ED visits in 2014. Multivariate analysis was performed on significant variables associated with IAs.

RESULTS

Among 120,606 attendances, 11,631 (9.6%) were IAs. Multivariate analysis showed that gender, ethnicity, referral source, time of ED visit, nationality and history of frequent visits to the ED were factors associated with IAs. Moreover, the odds of IA were found to be higher among attendees who were younger, were self-referred, or had at least one IA in 2014.

CONCLUSION

This study identified subgroups in the population who were more likely to contribute to IAs at the ED. These findings offer relevant insights into future research directions and strategies that might potentially reduce avoidable IAs.

Characteristics of Children Enrolled in Medicaid With High-Frequency Emergency Department Use

BACKGROUND AND OBJECTIVES

Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years.

METHODS

Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1-16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013-2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use.

RESULTS

A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3-1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1-1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9-2.3]) experienced the highest likelihood for sustaining high ED use.

CONCLUSIONS

One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk.

Cost Sharing in Medicaid: Assumptions, Evidence, and Future Directions

Several states have received waivers to expand Medicaid to poor adults under the Affordable Care Act using more cost sharing than the program traditionally allows. We synthesize literature on the effects of cost sharing, focusing on studies of low-income U.S. populations from 1995 to 2014. Literature suggests that cost sharing has a deterrent effect on initiation of treatments, and can reduce utilization of ongoing treatments. Furthermore, cost sharing may be difficult for low-income populations to understand, patients often lack sufficient information to choose medical treatment, and cost sharing may be difficult to balance within the budgets of poor adults. Gaps in the literature include evidence of long-term effects of cost sharing on health and financial well-being, evidence related to effectiveness of cost sharing combined with patient education, and evidence related to targeted programs that use financial incentives for wellness. Literature underscores the need for evaluation of the effects of cost sharing on health status and spending, particularly among the poorest adults.

The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review

STUDY OBJECTIVE

Previous reviews of emergency department (ED) visit reduction programs have not required that studies meet a minimum quality level and have therefore included low-quality studies in forming conclusions about the benefits of these programs. We conduct a systematic review of ED visit reduction programs after judging the quality of the research. We aim to determine whether these programs are effective in reducing ED visits and whether they result in adverse events.

METHODS

We identified studies of ED visit reduction programs conducted in the United States and targeted toward adult patients from January 1, 2003, to December 31, 2014. We evaluated study quality according to the Grading of Recommendations Assessment, Development, and Evaluation criteria and included moderate- to high-quality studies in our review. We categorized interventions according to whether they targeted high-risk or low-acuity populations.

RESULTS

We evaluated the quality of 38 studies and found 13 to be of moderate or high quality. Within these 13 studies, only case management consistently reduced ED use. Studies of ED copayments had mixed results. We did not find evidence for any increase in adverse events (hospitalization rates or mortality) from the interventions in either high-risk or low-acuity populations.

CONCLUSION

High-quality, peer-reviewed evidence about ED visit reduction programs is limited. For most program types, we were unable to draw definitive conclusions about effectiveness. Future ED visit reduction programs should be regarded as demonstrations in need of rigorous evaluation.

The impact of an emergency fee increase on the composition of patients visiting emergency departments

Objectives:

This study aimed to test our hypothesis that a raise in the emergency fee implemented on March 1, 2013 has increased the proportion of patients with emergent symptoms by discouraging non-urgent emergency department visits.

Methods:

We conducted an analysis of 728 736 patients registered in the National Emergency Department Information System who visited level 1 and level 2 emergency medical institutes in the two-month time period from February 1, 2013, one month before the raise in the emergency fee, to March 31, 2013, one month after the raise. A difference-in-difference method was used to estimate the net effects of a raise in the emergency fee on the probability that an emergency visit is for urgent conditions.

Results:

The percentage of emergency department visits in urgent or equivalent patients increased by 2.4% points, from 74.2% before to 76.6% after the policy implementation. In a group of patients transferred using public transport or ambulance, who were assumed to be least conscious of cost, the change in the proportion of urgent patients was not statistically significant. On the other hand, the probability that a group of patients directly presenting to the emergency department by private transport, assumed to be most conscious of cost, showed a 2.4% point increase in urgent conditions (p<0.001). This trend appeared to be consistent across the level 1 and level 2 emergency medical institutes.

Conclusions:

A raise in the emergency fee implemented on March 1, 2013 increased the proportion of urgent patients in the total emergency visits by reducing emergency department visits by non-urgent patients.

Non-emergency department interventions to reduce ED utilization: a systematic review

OBJECTIVES

Recent health policy changes have focused efforts on reducing emergency department (ED) visits as a way to reduce costs and improve quality of care. This was a systematic review of interventions based outside the ED aimed at reducing ED use.

METHODS

This study was designed as a systematic review. We reviewed the literature on interventions in five categories: patient education, creation of additional non-ED capacity, managed care, prehospital diversion, and patient financial incentives. Studies written in English, with interventions administered outside of the ED, and a comparison group where ED use was an outcome, were included. Two independent reviewers screened search results using MEDLINE, Cochrane, OAIster, or Scopus. The following data were abstracted from included studies: type of intervention, study design, population, details of intervention, effect on ED use, effect on non-ED health care use, and other health and financial outcomes. Quality of individual articles was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines.

RESULTS

Of 39 included studies, 34 were observational and five were randomized controlled trials. Two of five studies on patient education found reductions in ED use ranging from 21% to 80%. Out of 10 studies of additional non-ED capacity, four showed decreases of 9% to 54%, and one a 21% increase. Both studies on prehospital diversion found reductions of 3% to 7%. Of 12 studies on managed care, 10 had decreases ranging from 1% to 46%. Nine out of 10 studies on patient financial incentives found decreases of 3% to 50%, and one a 34% increase. Nineteen studies reported effect on non-ED use with mixed results. Seventeen studies included data on health outcomes, but 13 of these only included data on hospitalizations rather than morbidity and mortality. Seven studies included data on cost outcomes. According to the GRADE guidelines, all studies had at least some risk of bias, with four moderate quality, one low quality, and 34 very low quality studies.

CONCLUSIONS

Many studies have explored interventions based outside the ED to reduce ED use in various populations, with mixed evidence. Approximately two-thirds identified here showed reductions in ED use. The interventions with the greatest number of studies showing reductions in ED use include patient financial incentives and managed care, while the greatest magnitude of reductions were found in patient education. These findings have implications for insurers and policymakers seeking to reduce ED use.

Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review

Background

Emergency department (ED) utilization has dramatically increased in developed countries over the last twenty years. Because it has been associated with adverse outcomes, increased costs, and an overload on the hospital organization, several policies have tried to curb this growing trend. The aim of this study is to systematically review the effectiveness of organizational interventions designed to reduce ED utilization.

Methodology/Principal Findings

We conducted electronic searches using free text and Medical Subject Headings on PubMed and The Cochrane Library to identify studies of ED visits, re-visits and mortality. We performed complementary searches of grey literature, manual searches and direct contacts with experts. We included studies that investigated the effectiveness of interventions designed to reduce ED visits and the following study designs: time series, cross-sectional, repeated cross-sectional, longitudinal, quasi-experimental studies, and randomized trial. We excluded studies on specific conditions, children and with no relevant outcomes (ED visits, re-visits or adverse events). From 2,348 potentially useful references, 48 satisfied the inclusion criteria. We classified the interventions in mutually exclusive categories: 1) Interventions addressing the supply and accessibility of services: 25 studies examined efforts to increase primary care physicians, centers, or hours of service; 2) Interventions addressing the demand for services: 6 studies examined educational interventions and 17 examined barrier interventions (gatekeeping or cost).

Conclusions/Significance

The evidence suggests that interventions aimed at increasing primary care accessibility and ED cost-sharing are effective in reducing ED use. However, the rest of the interventions aimed at decreasing ED utilization showed contradictory results. Changes in health care policies require rigorous evaluation before being implemented since these can have a high impact on individual health and use of health care resources. Systematic review registration: http://www.crd.york.ac.uk/PROSPERO. Identifier: CRD420111253

An evaluation of statewide emergency department utilization following Tennessee Medicaid disenrollment

OBJECTIVES

During a series of reforms to the Tennessee Medicaid expansion program (TennCare) in 2005, approximately 171,000 adults were disenrolled from Medicaid. The objective of this study was to examine the statewide effect of such a disenrollment on Tennessee emergency department (ED) utilization.

METHODS

Administrative data on all ED visits in Tennessee from 2004 through 2006 were obtained from the State Emergency Department Database and State Inpatient Database under the Healthcare Utilization Project. Population statistics and uninsured estimates were obtained from the U.S. Census Bureau, and TennCare enrollment data were obtained from the State of Tennessee Department of TennCare. The proportion and rate of ED visits, assessed separately by payer type, were compared across a predisenrollment period from January 1, 2004, through July 31, 2005, and across a postdisenrollment period from August 1, 2005, through December 31, 2006. The proportion and rate of ED visits resulting in hospital admission, again assessed separately by payer type, were compared across the same disenrollment periods in a similar way. We fitted a series of linear models for the total number of ED visits and each proportion and rate, with various degrees of adjustment for seasonality and time trend.

RESULTS

The mean number of ED visits was 45,662 per week during the predisenrollment period and 44,463 per week during the postdisenrollment period (mean difference = -1,199; 95% confidence interval [CI] -1,722 to -676). By payer category, there was a decrease of 3,119 visits per week by TennCare beneficiaries and an increase of 2,203 per week by the uninsured. After disenrollment, the absolute proportion of ED visits by TennCare beneficiaries significantly decreased by 6.2% (95% CI = -6.6% to -5.8%), and the absolute proportion of uninsured ED visits increased by 5.3% (95% CI = 4.9% to 5.7%). The rate of ED visits by TennCare beneficiaries decreased by -0.091 ED visits/person/year (95% CI = -0.136 to -0.046) in the disenrollment period when controlling for time and seasonality. The rate of ED visits among the uninsured increased by 0.038 ED visits/person/year (95% CI = 0.011 to 0.065) in the postdisenrollment period when controlling for cubic time trend. The proportion of all TennCare ED visits that resulted in hospital admission did not change significantly between the two periods after adjusting for time trend and seasonality. The proportion of uninsured ED visits resulting in hospital admission, however, significantly increased after disenrollment by 2.0% (95% CI = 1.8% to 2.2%) and by 0.6% (95% CI = 0.0% to 1.2%) after adjusting for time and seasonality.

CONCLUSIONS

The TennCare disenrollment of 2005 was associated with a modest decrease in the number of total ED visits in Tennessee. However, the payer mix among the Tennessee ED population shifted abruptly. The increased rate of ED visits by Tennessee's uninsured and the increased proportion of uninsured ED visits leading to hospital admission suggest an increased burden of illness in this highly vulnerable population.