Emergency department use by the uninsured after health care reform in Massachusetts

The Affordable Care Act and emergency department use by low acuity patients in a US hospital

BACKGROUND

The Affordable Care Act (ACA) is one of the biggest healthcare reforms in US history. A key issue is the ACAs effect on low acuity, potentially primary care patients. This study evaluates the effect of the ACA on low acuity patients seen in the emergency department (ED).

METHODS

This is an age-period-cohort analysis for a community hospital ED in Michigan, from 2009 to 2015. Patients were stratified by age, year seen, emergency severity index (ESI) and insurance status. Data were compared between before and after ACA along with descriptive statistics, Chi-square and Student t-tests. The primary outcome was the change in ED usage by low acuity. Patients > 65 were used as a temporal control.

RESULTS

305,350 ED visits were analyzed. ED visits with ESI 4/5 increased from 11.9% to 14.8%. Patients < 19 years increased from 25.5% to 34.3% (p = .0026). Ages 19-25 increased from 16.3% to 19.7% (p = 0.0515). Ages 26-64 increased from 11% to 14.9% (p = 0.0129). Ages > 65 increased from 5.1% to 6.5%. Patients < 65 showed a decreased uninsured rate from 12.30% to 6.28% (p < 0.0001). Comparatively, for age > 65: uninsured rate remained the same 0.46% to 0.49%.

CONCLUSION

Low acuity ED visits increased with the ACA reform in conjunction with a more insured population.

Trends in Pediatric Emergency Department Use After the Affordable Care Act

OBJECTIVES

After the Affordable Care Act (ACA) took full effect in 2014, 900 000 children obtained health insurance. Researchers have found variable effects of insurance on adult emergency department (ED) use, but the effect in pediatric patients is unknown. We examined ED visit rates before and after 2014 among children.

METHODS

We used estimates of ED visit counts from the Nationwide Emergency Department Sample and population estimates from the American Community Survey in a cross-sectional, retrospective study of ED visit rates among children. We compared the trend in ED visit rates before (2009-2013) and after (2014-2016) the ACA took full effect, controlling for age, sex, and census region.

RESULTS

The mean ED use rate was 35.2 visits per 100 children from 2009 to 2013 and 36.6 from 2014 to 2016. ED visit rates increased by 1.1% per year pre-2014 and 9.8% from 2014 to 2016 (incidence rate ratio 1.09, 95% confidence interval 1.03-1.15, P = .005). Results did not vary significantly when insurance was included as a control variable.

CONCLUSIONS

There was no immediate change in pediatric ED visit rates the year after the ACA took full effect in 2014, but the rate of change from 2014 to 2016 was significantly higher than previous rate trends. In our model, increased pediatric insurance coverage neither drove nor counteracted the observed trends.

The Affordable Care Act: Disparities in emergency department use for mental health diagnoses in young adults

BACKGROUND

There is little consensus as to the effects of insurance expansion on emergency department (ED) utilization for mental health purposes. We aimed to study the race specific association between the dependent coverage provision of the Affordable Care Act (ACA) and changes in young adults' usage of emergency department services for psychiatric diagnoses.

METHODS

We utilized a Quasi-Experimental analysis of ED use in California from 2009-2011 for behavioral health diagnoses of individuals aged 19 to 31 years. Analysis used a difference-in-differences approach comparing those targeted by the ACA dependent provision (19-25 years) and those who were not (27 to 31 years), evaluating changes in ED visit rates per 1 000 in California. Primary outcomes measured included the quarterly ED visit rates with any psychiatric diagnosis. Subgroups were analyzed for differences based on race and gender.

RESULTS

The ACA dependent provision was associated with 0.05 per 1 000 people fewer psychiatric ED visits among the treatment group (19-25 years) compared to the control group (27-31 years). Hispanics and Asian/Pacific Islanders were the only racial subgroups who did not see this significant reduction and were the only racial subgroups that did not see significant gains in the proportion of psychiatric ED visits covered by private insurance.

CONCLUSION

The ACA dependent provision was associated with a modest reduction in the growth rate of ED use for psychiatric reasons, however, racial disparities in the effect of this provision exist for patients of Hispanic and Asian/Pacific Islander racial groups.

ED Utilization by Uninsured and Medicaid Patients after Availability of Telephone Triage

PROBLEM

For emergency departments experiencing crowding and a high percentage of patients leaving without being seen, a telephone triage service can provide other care options for low-acuity patients.

METHODS

A nonexperimental pre- and postintervention comparative design was used to measure ED visit volumes from Medicaid and uninsured patients presenting with a low-acuity health care problem. Visit volumes for the 12 months before and 12 months after the initiation of telephone triage were compared.

RESULTS

The overall low-acuity visit volume increased in the first 12 months of telephone triage availability. However, the proportion of low-acuity Medicaid and uninsured patients seeking ED care decreased. For the first 12 months of operation, telephone triage received 10,055 calls. Sixty percent of the calls (N = 6086) were from uninsured and Medicaid patients. More than 43% of the calls resulted in a self-care decision.

IMPLICATIONS FOR PRACTICE

A telephone triage service may help decrease ED crowding by communicating other care options to patients with low-acuity health problems.

Innovative methods for parents and clinics to create tools for kids' care (IMPACCT Kids' Care) study protocol

BACKGROUND

Despite expansions in public health insurance, many children remain uninsured or experience gaps in coverage. Community health centers (CHCs) provide primary care to many children at risk for uninsurance and are well-positioned to help families obtain and retain children's coverage. Recent advances in health information technology (HIT) capabilities provide the means to create tools that could enhance CHCs' insurance outreach efforts.

OBJECTIVE

To present the study design, baseline patient characteristics, variables, and statistical methods for the Innovative Methods for Parents And Clinics to Create Tools for Kids' Care (IMPACCT Kids' Care) study.

METHODS/DESIGN

In this mixed methods study, we will design, test and refine health insurance outreach HIT tools through a user-centered process. We will then implement the tools in four CHCs and evaluate their effectiveness and barriers and facilitators to their implementation. To measure effectiveness, we will quantitatively assess health insurance coverage continuity and utilization of healthcare services for pediatric patients in intervention CHCs compared to matched control sites using electronic health record (EHR) and Oregon Medicaid administrative data over 18months pre- and 18months post-implementation (n=34,867 children). We will also qualitatively assess the implementation process to understand how the tools fit into the clinics' workflows and the CHC staff experiences with the tools.

CONCLUSIONS

This study creates, implements, and evaluates health insurance outreach HIT tools. The use of such tools will likely improve care delivery and health outcomes, reduce healthcare disparities for vulnerable populations, and enhance overall healthcare system performance. ClinicalTrials.gov Identifier: NCT02298361.

The impact of insurance and a usual source of care on emergency department use in the United States

Background. Finding a usual source of care (USC) is difficult for certain populations. This analysis determines how insurance type and having a USC affect the settings in which patients seek care. Methods. In this cross-sectional study of the 2000-2011 Medical Expenditure Panel Surveys, we assessed the percentage of low-income persons with half or more of their ambulatory visits to the emergency department (ED). Respondents were stratified based on insurance type and presence of a USC. Results. In 2011, among Medicaid enrollees without USCs, 21.6% had half or more of their ambulatory visits to EDs compared to 8.1% for those with USCs. Among the uninsured without USCs, 24.1% went to an ED for half or more of their ambulatory visits compared to 8.8% for those with USCs in 2011. Among the privately insured without USCs, 7.8% went to an ED for half or more of their ambulatory visits compared to 5.0% for those with USCs in 2011. These differences remained in multivariate analyses. Conclusions. Those who lack USCs, particularly the uninsured and Medicaid enrollees, are more likely to rely on EDs.

Association of emergency department length of stay with safety-net status

CONTEXT

Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients.

OBJECTIVE

To describe emergency department (ED) compliance with proposed length-of-stay measures for admissions (8 hours or 480 minutes) and discharges, transfers, and observations (4 hours or 240 minutes) by safety-net status.

DESIGN, SETTING, AND PARTICIPANTS

The 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (Centers for Disease Control and Prevention definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34 134 patient records. Visits were excluded for patients younger than 18 years, missing length-of-stay data or dispositions of missing, other, left against medical advice, or dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariable analyses determined associations with length-of-stay measure compliance.

MAIN OUTCOME MEASURES

Emergency Department length-of-stay measure compliance by disposition and safety-net status.

RESULTS

Of the 72.1% ED visits (N = 24 719) included in the analysis, 42.3% were to safety-net EDs and 57.7% were to non-safety-net EDs. The median length of stay for safety-net was 269 minutes (interquartile range [IQR], 178-397 minutes) for admission vs 281 minutes (IQR, 178-401 minutes) for non-safety-net EDs; 156 minutes (IQR, 95-239 minutes) for discharge vs 148 minutes (IQR, 88-238 minutes); 355 minutes (IQR, 221-675 minutes) for observations vs 298 minutes (IQR, 195-440 minutes); and 235 minutes (IQR, 155-378 minutes) for transfers vs 239 minutes (IQR, 142-368 minutes). Safety-net status was not independently associated with compliance with ED length-of-stay measures; the odds ratio was 0.83 for admissions (95% CI, 0.52-1.34); 1.03 for discharges (95% CI, 0.83-1.27); 1.05 for observations (95% CI, 0.57-1.95), 1.30 for transfers (95% CI, 0.70-2.45]); or subcategories except for psychiatric discharges (1.67, [95% CI, 1.02-2.74]).

CONCLUSION

Compliance with proposed ED length-of-stay measures for admissions, discharges, transfers, and observations did not differ significantly between safety-net and non-safety-net hospitals.

Effects of healthcare reforms on coverage, access, and disparities: quasi-experimental analysis of evidence from Massachusetts

BACKGROUND

The 2010 Patient Protection and Affordable Care Act (PPACA) has been controversial. The potential impact of national healthcare reform may be considered using a similar set of state-level reforms including exchanges and a mandate, enacted in 2006 in Massachusetts.

PURPOSE

To evaluate the effects of reforms on healthcare access, affordability, and disparities.

DESIGN

Interrupted time series with comparison series.

SETTING/PARTICIPANTS

Longitudinal survey data from 2002 to 2009 from the Behavioral Risk Factor Surveillance System including 178,040 nonelderly adults residing in Massachusetts, Vermont, New Hampshire, Rhode Island, and Connecticut. Analysis was conducted from January to August 2010.

INTERVENTION

Massachusetts 2006 healthcare reform, which included an individual health insurance mandate.

MAIN OUTCOME MEASURES

Being uninsured, having no personal doctor, and forgoing care because of cost, evaluated in Massachusetts and four comparison states before (2002-2005) and after (2007-2009) the healthcare reform. Effects on disparities defined by race, education, income, and employment also were assessed.

RESULTS

Living in Massachusetts in 2009 was associated with a 7.6 percentage point (95% CI=3.9, 11.3) higher probability of being insured; 4.8 percentage point (-0.9, 10.6) lower probability of forgoing care because of cost; and a 6.6 percentage point (1.9, 11.3) higher probability of having a personal doctor, compared to expected levels in the absence of reform, defined by trends in control states and adjusting for socioeconomic factors. The effects of the reform on insurance coverage attenuated from 2008 to 2009. In a socioeconomically disadvantaged group, the reforms had a greater effect in improving outcomes on the absolute but not relative scale.

CONCLUSIONS

Healthcare reforms in Massachusetts, which included a health insurance mandate, were associated with significant increases in insurance coverage and access. The absolute effects of the reform were greater for disadvantaged populations. This is important evidence to consider as debate over national healthcare reform continues.

Emergency department utilization after the implementation of Massachusetts health reform

STUDY OBJECTIVE

Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions.

METHODS

We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation.

RESULTS

Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%).

CONCLUSION

Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.