Copayments and Emergency Department Use Among Adult Medicaid Enrollees.

A number of state Medicaid programs have recently proposed or implemented new or increased copayments for nonemergent emergency department (ED) visits. Evidence suggests that copayments generally reduce the level of healthcare utilization, although there is little specific evidence regarding the effectiveness of copayments in reducing nonurgent ED use among Medicaid enrollees or other low-income populations. Encouraging efficient and appropriate use of healthcare services will be of particular importance for Medicaid programs as they expand under the Patient Protection and Affordable Care Act. This analysis uses national data from 2001 to 2009 to examine the effect of copayments on nonurgent ED utilization among nonelderly adult enrollees. We find that visits among Medicaid enrollees in state-years where a copayment is in place are significantly less likely to be for nonurgent reasons. Our findings suggest that copayments may be an effective tool for reducing use of the ED for nonurgent care.

Trends in nonemergent use of emergency departments by health insurance status.

This article describes trends in nonemergent emergency department (ED) visits by insurance type, using the 2000-2009 National Hospital Ambulatory Medical Care Survey and Current Population Survey. We analyzed trends in the probability that an ED visit is nonemergent and in nonemergent ED visit rates per person. We found that visits for Medicare enrollees were least likely to be for nonemergent reasons, while uninsured visits were most likely to be nonemergent. When we accounted for total visits and population size by insurance group, we found nonemergent ED visit rates per person were largest among Medicaid enrollees. Trends in nonemergent ED visit rates were stable for all insurance groups. The findings suggest a reliance on the ED for nonemergent care by the Medicaid population. It will be important to continue to track patterns of nonemergent ED utilization after Medicaid expansions under the Affordable Care Act.

Emergency department visit classification using the NYU algorithm.

OBJECTIVES: Reliable measures of emergency department (ED) use are important for studying ED utilization and access to care. We assessed the association of emergent classification of an ED visit based on the New York University ED Algorithm (EDA) with hospital mortality and hospital admission. STUDY DESIGN: Using diagnosis codes, we applied the EDA to classify ED visits into emergent, intermediate, and nonemergent categories and studied associations of emergent status with hospital mortality and hospital admissions. METHODS: We used a nationally representative sample of patients with visits to hospital-based EDs from repeated cross sections of the National Hospital Ambulatory Medical Care Survey from 2006 to 2009. We performed survey-weighted logistic regression analyses, adjusting for year and patient demographic and socioeconomic characteristics, to estimate the association of emergent ED visits with the probability of hospital mortality or hospital admission. RESULTS: The EDA measure of emergent visits was significantly and positively associated with mortality (odds ratio [OR]: 3.79, 95% confidence interval [CI]: 2.50-5.75) and hospital admission (OR: 5.28, 95% CI, 4.93-5.66). CONCLUSIONS: This analysis assessed the NYU algorithm in measuring emergent and nonemergent ED use in the general population. Emergent classification based on the algorithm was strongly and significantly positively associated with hospitalization and death in a nationally representative population. The algorithm can be useful in studying ED utilization and evaluating policies that aim to change it.

Impact of changes in Medicaid coverage on physician provision of safety net care.

BACKGROUND: The Patient Protection and Affordable Care Act will expand Medicaid coverage substantially, with the goal of improving the health of low-income individuals and reducing disparities in coverage and access. Whether insurance expansions are successful in achieving this goal will depend in part on physician response to changes in insurance coverage mix and the effect of this response on access to care for low-income safety net populations. OBJECTIVES: The objective of the study was to consider the impact of changes in market-level Medicaid coverage on measures of physician participation in care for safety net populations. RESEARCH DESIGN: We use 4 waves of the Community Tracking Study Physician Survey from 1996 to 2005. We estimate both market-level and physician-level fixed effects models, to consider changes in market-level Medicaid rates on measures of physician acceptance of new patients (both Medicaid patients and uninsured patients unable to pay), revenue from Medicaid, and provision of charity care. We also stratify the sample to investigate whether effects differ among office-based versus facility-based physicians. RESULTS: Increases in Medicaid coverage are associated with statistically significant decreases in the likelihood that physicians will accept new uninsured patients who are unable to pay, particularly among office-based physicians. Increases in Medicaid coverage are not associated with changes in acceptance of new Medicaid patients. CONCLUSIONS: Past changes in Medicaid coverage rates are not associated with changes in physician acceptance of new Medicaid patients or provision of charity care, although they are associated with lower acceptance of new uninsured patients, particularly among office-based physicians.

Differences between non-profit and for-profit hospices: patient selection and quality.

This research compares the behavior of non-profit organizations and private for-profit firms in the hospice industry, where there are financial incentives created by the Medicare benefit. Medicare reimburses hospices on a fixed per diem basis, regardless of patient diagnosis. Because under this system patients with lower expected costs are more profitable, hospices can selectively enroll patients with longer lengths of stay. While it is illegal for hospices to reject potential patients explicitly, they can influence their patient mix through referral networks. A fixed per diem rate also creates an incentive shirk on quality and to substitute lower skilled for higher skilled labor, which has implications for quality of care. By using within-market variation in hospice characteristics, the empirical evidence suggests that for-profit hospices differentially take advantage of these incentives. The results show that for-profit hospices engage in patient selection through significantly different referral networks than non-profits. They receive more patients from long-term care facilities and fewer patients through more traditional paths, such as physician referrals. This mechanism of patient selection is supported by the result that for-profits have fewer cancer patients and more patients with longer lengths of stay. While non-profit and for-profit hospices report similar numbers of staff visits per patient, for-profit firms make significantly less use of skilled nursing providers. We also find some weak evidence of lower levels of quality in for-profit hospices.

Lessons for coverage expansion: a Virginia primary care program for the uninsured reduced utilization and cut costs.

The Affordable Care Act will expand health insurance coverage for an estimated thirty-two million uninsured Americans. Increased access to care is intended to reduce the unnecessary use of services such as emergency department visits and to achieve substantial cost savings. However, there is little evidence for such claims. To determine how the uninsured might respond once coverage becomes available, we studied uninsured low-income adults enrolled in a community-based primary care program at Virginia Commonwealth University Medical Center. For people continuously enrolled in the program, emergency department visits and inpatient admissions declined, while primary care visits increased during the study period. Inpatient costs fell each year for this group. Over three years of enrollment, average total costs per year per enrollee fell from $8,899 to $4,569--a savings of almost 50 percent. We conclude that previously uninsured people may have fewer emergency department visits and lower costs after receiving coverage but that it may take several years of coverage for substantive health care savings to occur.