Community Emergency Care Use by Veterans in an Era of Expanding Choice.

Importance: Recently passed legislation aimed at improving access to care has considerably expanded options for veterans to receive emergency care in community, or non-Veterans Affairs (VA) settings. However, national trends in community emergency department (ED) use by veterans are unknown. Objective: To examine national, temporal trends in the frequencies and types of ED visits provided in community settings and explore the association between facilities' purchase of community care with facility and regional characteristics. Design, Setting, and Participants: Retrospective, observational cross-sectional study of ED visits over fiscal years (FY) 2016 to 2022. VA and community ED encounter data were obtained from the VA Corporate Data Warehouse and the Office of Integrated Veteran Care. Participants were veterans receiving ED care at VA facilities or paid for by the VA in the community. Data were analyzed from June to September 2023. Main Outcomes and Measures: The primary outcome measures included community ED visit volume, disposition, and payments over time. Also, the most common and costly ED visits were assessed. Negative binomial regression analysis examined associations between facility and regional characteristics and the rate of ED visits purchased in community settings relative to all ED visits. Results: There were 19 787 056 ED visits, predominantly at VA facilities (14 532 261 visits [73.4%]), made by 3 972 503 unique veterans from FY 2016 to 2022. The majority of ED users were male (3 576 120 individuals [90.0%]), and the median (IQR) age was 63 (48-73) years. The proportion of community ED visits increased in absolute terms from 18% in FY 2016 to 37% in FY 2022. Total community ED payments, adjusted to 2021 dollars, were $1.18 billion in FY 2016 and over $6.14 billion in FY 2022. The most common reasons for ED visits in the community were for nonspecific chest pain (305 082 visits [6%]), abdominal pain (174 836 visits [3%]), and septicemia (149 968 visits [3%]). The average proportion of ED visits purchased by a VA facility increased from 14% in FY 2016 to 32% by FY 2022. In multivariable analyses, facilities with greater ED volume and low-complexity facilities had higher expected rates of community emergency care than lower volume and high-complexity facilities, respectively. Conclusions and Relevance: As veterans increasingly use community EDs for acute, unscheduled needs, attention to factors associated with veterans' use of acute care services in different settings are important to identify access barriers and to ensure veterans' health care needs are met.

Do hospital-based emergency Medicaid programs benefit trauma centers? A mixed-methods analysis.

INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization, which can offset patient costs of care, increase access to postdischarge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement and characterize incentives for HPE participation among hospitals and TCs. We hypothesized that there would be financial, operational, and mission-based incentives. METHODS: We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semistructured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8). RESULTS: Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE, 77 (21%) of which are TCs. As of early 2015, 100% of TCs had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II TCs. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue ( b = 6.74, p < 0.001) and decreased uncompensated care costs ( b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included reduction of hospital bad debt, improved patient satisfaction, and community benefit in access to care. CONCLUSION: Hospital Presumptive Eligibility programs not only are a promising pathway for long-term insurance coverage for trauma patients but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program. LEVEL OF EVIDENCE: Economic And Value Based Evaluations; Level II.

State-Level Variability in Hospital Presumptive Eligibility Programs.

This cross-sectional study examines state-level variability in hospital presumptive eligibility programs to understand discrepancies in access by Medicaid expansion status.

Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans.

OBJECTIVES: Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs. METHODS: Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC-specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition-specific multivariable models. RESULTS: The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs-chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition-specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition-specific age subgroups. CONCLUSIONS: We identified unexplained facility-level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems-based levers to improve value in VA emergency care.

Emergency Medicaid programs may be an effective means of providing sustained insurance among trauma patients: A statewide longitudinal analysis.

BACKGROUND: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to postdischarge resources, and provides patients with a path to sustain coverage through Medicaid. Because HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status 6 months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment. METHODS: Using a customized longitudinal claims data set for HPE-approved patients from the California Department of Health Care Services, we analyzed adults with a primary trauma diagnosis (International Classification of Diseases version 10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at 6 months. Univariate and multivariate analyses were performed. RESULTS: A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at 6 months. Compared with patients who did not sustain, those who sustained had higher Injury Severity Score (ISS > 15: 73.5% vs. 68.7%, p < 0.001), more frequent surgical intervention (74.8% vs. 64.5%, p < 0.001), and were more likely to be discharged to postacute services (23.9% vs. 10.4%, p < 0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%), and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS > 16) (vs. ISS < 15: adjusted odds ratio [aOR], 1.51; p = 0.02) and surgery (aOR, 1.85; p < 0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR, 0.05; p < 0.001) decreased the likelihood of Medicaid sustainment. CONCLUSION: Hospital Presumptive Eligibility programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to health care services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage.

INTRODUCTION: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS: We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION: The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. LEVEL OF EVIDENCE: Economic, level IV.

Emergency Medicaid Acquisition Through the Affordable Care Act: The Association Between Hospital Enrollment in California and Hospital Revenue.

BACKGROUND: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue. OBJECTIVE: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals. RESEARCH DESIGN: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges. RESULTS: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, ∼33,000 adults and children were enrolled in California's HPE program per month. CONCLUSION: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.