Medicaid expansion and resource utilization in the emergency department

BackgroundThe Affordable Care Act (ACA) has impacted the insurance mix of emergency department (ED) visits, yet the degree to which this has influenced provider behavior is not clear.MethodsThis was a difference-in-differences (DID) analysis of ED-visit data from five states in 2013 and 2014. Sample states included 3 expanding Medicaid under the ACA, 1 rejecting ACA funding and delaying an eligibility expansion, and 1 with no eligibility change. We included self-pay and Medicaid patients aged 27 to 64 years. A subsample analysis was done for chest pain visits. DID logistic models were estimated for likelihood of admission for given Medicaid-paid ED visits in expansion states as compared to non-expansion states. Among chest pain visits we assessed likelihood given visits resulted in admission or advanced cardiac imaging, where clinician discretion may be more significant.ResultsA total of 8,157,748 ED visits with primary payer Medicaid and self-pay were included, of which 331,422 were for chest pain. The proportion of visits paid for by Medicaid rose in expansion states by between 15.8% and 38.9%. Medicaid eligibility expansion was associated with increased odds of admission (OR 1.070 [95% CI 1.051–1.089]). Among chest pain visits, expansion was associated with increased odds of admission (OR 1.294 [95% CI 1.144–1.464]), but not advanced cardiac imaging (OR 1.099 [95% CI 0.983–1.229]).ConclusionMedicaid expansion was associated with small increases in ED visit admissions across the board and among the subgroup of patients presenting with chest pain.     

The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York

BackgroundOne of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York.MethodsWe used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses.ResultsAfter ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681–17,522) and in rates (0.80, 95% CI:0.12–1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 –31,704) while ED visits by the uninsured declined by 13,297 (95% CI:−15,856 – −10,737), and by 1453 (95% CI:-4027–1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96–3.51) and by 2.18 (95% CI:-0.55–4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 – -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries.ConclusionNet ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.     

Factors influencing inappropriate use of ED visits among type 2 diabetics in an evidence‐based management programme

Object This study analyses inappropriate use of emergency department (ED) services among type 2 diabetics under an evidence‐based management programme. Methods Using 1999‐2006 databases of Louisiana Health Care Services Division (HCSD) eight public hospitals ED visits among the uninsured and other patients in Louisiana, we termed urgent ED visits appropriate and less‐urgent visits inappropriate. Eliminating weekend ED visits, 17 458 urgent and 22 395 less‐urgent visits by 8596 patients were analysed, using generalized estimating equation methods. Results Caucasians were 0.82 times (95% CI: 0.751–0.889) less likely to use the ED inappropriately compared with African Americans. Patients with commercial insurance, Medicaid and Medicare used the ED more inappropriately than uninsured, with odds ratios of 1.28, 1.32 and 1.28, respectively. Patients hospitalized the prior year were 0.84 times (95% CI: 1.08–1.31) less likely for inappropriate. Patients in larger hospitals used the ED more inappropriately, with an odds ratio of 1.44 (95% CI: 1.32–1.56). Conclusions The study suggests that inappropriate use of the ED among diabetic patients in an evidence‐based management programme is more likely to occur among African American, patients with insurance coverage and those seeking care in larger hospitals. Reinforcing the regular use of clinic services for diabetes management, providing clinic access in off‐hours, and engaging the health plans in providing incentives for more appropriate use of the ED might reduce inappropriate ED visits. Notably, uninsured patients with diabetes from HCSD were more efficient users of the ED.     

The Affordable Care Act and child asthma: Lowering health care barriers by raising our voices

BackgroundThis policy discussion addresses the provisions of the Affordable Care Act (ACA) that impact children with asthma.PurposeThe purpose of this policy paper is to inform health care professionals and lawmakers about ACA provisions affecting pediatric asthma care and provide recommendations for policy changes that can improve equitable care for children with asthma.MethodsThe issues addressed involve discrimination, Medicaid policy oversight, quality improvement stategy, data collection, school-based health care funding, accountable care organization reimbursement, and the extension of dependent coverage.DiscussionHealth care policy development that focuses on human rights, and not market valuation, could reduce health inequity among children with asthma.ConclusionPolicy recommendations are presented to improve asthma care for a population that is largely vulnerable due to age, socioeconomic status, and discrimination.     

End-of-life trends and patterns among children in the US foster care system: 2005–2015

Drawing on national, longitudinal Adoption and Foster Care Analysis, and Reporting System data (2005–2015), demographic, health, foster care, and geographic characteristics of decedents (N?=?3653) aged 1–17 years were examined. On average, decedents were 6 years old, the highest proportion died as infants, and experienced significant trauma in their short lives either through maltreatment or exposure to parental substance use. A noted increase in Medicaid coverage among decedents over time suggests critical access to concurrent treatment and hospice care, but this is unavailable to children with private insurance. This study has policy implications related to the 2010 Affordable Care Act.     

Racial and insurance disparities among patients presenting with chest pain in the US: 2009–2015

BackgroundNationally representative studies have shown significant racial and socioeconomic disparities in the triage and diagnostic evaluation of patients presenting to the emergency department (ED) with chest pain. However, these studies were conducted over a decade ago and have not been updated amidst growing awareness of healthcare disparities.ObjectiveWe aimed to reevaluate the effect of race and insurance type on triage acuity and diagnostic testing to assess if these disparities persist.MethodsWe identified ED visits for adults presenting with chest pain in the 2009–2015 National Hospital Ambulatory Health Care Surveys. Using weighted logistic regression, we examined associations between race and payment type with triage acuity and likelihood of ordering electrocardiography (ECG) or cardiac enzymes.ResultsA total of 10,441 patients met inclusion criteria, corresponding to an estimated 51.4 million patients nationwide. When compared with white patients, black patients presenting with chest pain were less likely to have an ECG ordered (adjusted odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.69–0.99). Patients with Medicare, Medicaid, and no insurance were also less likely to have an ECG ordered compared to patients with private insurance (Medicare: OR = 0.79, CI = 0.63–0.99; Medicaid: OR = 0.67, CI = 0.53–0.84; no insurance: OR = 0.68, CI = 0.55–0.84). Those with Medicare and Medicaid were less likely to be triaged emergently (Medicare: OR = 0.84, CI = 0.71–0.99; Medicaid: OR = 0.76, CI = 0.64–0.91) and those with Medicare were less likely to have cardiac enzymes ordered (OR = 0.84, CI = 0.72–0.98).ConclusionsPersistent racial and insurance disparities exist in the evaluation of chest pain in the ED. Compared to earlier studies, disparities in triage acuity and cardiac enzymes appear to have diminished, but disparities in ECG ordering have not. Given current Class I recommendations for ECGs on all patients presenting with chest pain emergently, our findings highlight the need for improvement in this area.     

Effects of the ACA Medicaid expansions on access and health by nurse practitioner scope of practice laws

BackgroundThe Affordable Care Act (ACA) Medicaid expansions increased demand for care whereas the Scope of Practice (SOP) laws for nurse procatitioners affect the supply of primary care providers. It is important to udnerstand the interaction of the demand and supply side policies on measures of access to care and health status.PurposeTo examine whether effects of the Affordable Care Act (ACA) Medicaid expansions on access to care and health status are moderated by state scope of practice (SOP) laws for nurse practitioners.MethodsUsing data from the 2011 to 2019 Behavioral Risk Factor Surveillance System, the study used a difference-in-differences design that compared outcome changes between expansion and non-expansion states and evaluated whether these changes differed by state SOP laws.DiscussionFollowing Medicaid expansion, forgoing a needed doctor's visit due to cost declined more in expansion states with full SOP laws than states with reduced SOP laws by 3.0 percentage-points in years 1 to 3 after the expansion (p < .05). Furthermore, completing a routine checkup with a doctor increased more in expansion states with full SOP laws by 3.2 percentage-points in 4 to 6 years (p < .05).ConclusionThe ACA Medicaid expansions were associated with larger gains in certain access measures in states with full SOP laws.     

Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006–2015

BackgroundAcute pain from a vaso-occlusive crisis (VOC) is a leading reason patients with sickle cell disease (SCD) visit the emergency department (ED). Prior studies suggest that women and men receive disparate ED treatment for acute pain in EDs. We aim to determine sex differences in analgesic use among patients with SCD presenting to the ED.MethodsThis cross-sectional study uses data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006–2015. We identified ED patients with a primary diagnosis of SCD. Among patients with SCD, we evaluated sex differences in the use of opioid analgesia using logistic regression (adjusting for patient and visit characteristics). Analyses accounted for survey design and weighting.ResultsWhen evaluating the effect of sex on any opioid medication use in this population, though not significant, the odds that male patients were prescribed opioids was 1.5 (95% CI 0.8–2.8) times that of female patients after adjusting for age, the reason for visit, region, insurance status, and pain score. There was no significant difference in pain scores between male patients, 8.1 (95% CI 7.55–8.68) compared to female patients, 7.4 (95% CI 6.7–8.12).ConclusionsIn this nationally representative sample of ED visits among patients with SCD, there was no conclusive evidence of sex disparities in opioid prescribing. Though there is evidence of a trend signaling that male patients with SCD were more likely than female patients to be prescribed an opioid.     

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.     

National trends in mental health-related emergency department visits by children and adults, 2009–2015

ObjectivesExamine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits.MethodsRetrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis.ResultsMental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15–64 year-olds and nearly 9% by 10–14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6–5.3) of all pediatric and 11.1% (95% CI 11.0–11.3) of adult ED treatment hours.ConclusionsMental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.     

Decreased hospital admissions through emergency departments during the COVID-19 pandemic

Study objectiveEmergency Department (ED) visits decreased significantly in the United States during the COVID-19 pandemic. A troubling proportion of this decrease was among patients who typically would have been admitted to the hospital, suggesting substantial deferment of care. We sought to describe and characterize the impact of COVID-19 on hospital admissions through EDs, with a specific focus on diagnosis group, age, gender, and insurance coverage.MethodsWe conducted a retrospective, observational study of aggregated third-party, anonymized ED patient data. This data included 501,369 patient visits from twelve EDs in Massachusetts from 1/1/2019–9/9/2019, and 1/1/2020–9/8/2020. We analyzed the total arrivals and hospital admissions and calculated confidence intervals for the change in admissions for each characteristic. We then developed a Poisson regression model to estimate the relative contribution of each characteristic to the decrease in admissions after the statewide lockdown, corresponding to weeks 11 through 36 (3/11/2020–9/8/2020).ResultsWe observed a 32% decrease in admissions during weeks 11 to 36 in 2020, with significant decreases in admissions for chronic respiratory conditions and non-orthopedic needs. Decreases were particularly acute among women and children, as well as patients with Medicare or without insurance. The most common diagnosis during this time was SARS-CoV-2.ConclusionOur findings demonstrate decreased hospital admissions through EDs during the pandemic and suggest that several patient populations may have deferred necessary care. Further research is needed to determine the clinical and operational consequences of this delay.     

Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds

BackgroundInpatient hallway beds are one solution to mitigate emergency department (ED) crowding due to boarding of admitted patients. Alternative Care Areas (AltCA) beds are located in inpatient hallways, cardiac catheterization lab, and endoscopy. We examined whether AltCA beds were associated with increased risk of patient safety and quality outcomes: transfer to Intensive Care Unit (ICU), mortality, hospital-acquired infections (HAI), falls, and 72-hour hospital readmission.MethodsRetrospective cohort study of patients age >18 years admitted from the ED to non-ICU beds at an urban, academic hospital. AltCA bed exclusion criteria: dementia, frequent respiratory interventions, contact or airborne isolation, psychiatric admission, and inability to ambulate. The study periods were: pre-intervention 9/1/2014–3/31/2015, transition 9/1/2015–3/31/2016, and post-intervention 9/1/2016–3/31/2017. Data analysis used unadjusted and multivariable analyses which controlled for age, sex, race, ethnicity, insurance, ED triage Emergency Service Index (ESI) level, and telemetry order.ResultsThe study included 16,801 patients, with 622 (3.7%) patients in AltCA beds. AltCA beds had younger patients than standard inpatient beds, 57.7 years and 61.7 years; fewer telemetry order, 48.4% and 59.3%; and fewer ESI level 2, 16.1% and 26.2%. AltCA beds had shorter hospital LOS than standard inpatient beds, 2.7 days and 3.4 days. AltCA beds had decreased risk of transfer to ICU −10.6 (95%CI: −18.3, −2.8) and HAI −13.4 (95%CI: −20.3, −6.5) compared to standard inpatient beds.ConclusionPatients in AltCA beds did not have increased risk of patient safety and quality outcomes but rather decreased risk of transfer to ICU and HAI than standard inpatient beds.     

Burden of non-fatal opioid overdose hospitalizations on Medicaid

ABSTRACT

Background: The Medicaid population experienced an elevated risk of opioid overdose death. Higher risks of a health condition or worse health outcomes could mean high costs imposed on public sources of insurance. In this study, we compared the length of stay and total charge of hospitalized opioid overdose patients across insurance types to shed light on the financial burden of opioid epidemic across different types of payers. Method: Our sample includes all opioid overdose hospitalizations in the 2012–2013 South Carolina Patient Encounter database. Length of stay and total hospital charge are the two dependent variables. The key independent variable is the insurance status, categorized as: self-pay, commercial insurance, Medicare, Medicaid, and other payers (other government plan and charitable plans). Multilevel models were applied to account for the clustering effect of each hospital. The patients’ age, gender, race/ethnicity, and Charlson Comorbidity Index were used as covariates. Results: A total of 1,262 hospitalizations were included. Medicaid patients stayed longer in hospital (β = 1.815, 95% confidence interval = [0.406–3.224]) and had higher total charge (β = $6,695.2, 95% CI = [215.1–13,175.3) compared with patients with commercial insurance. Conclusion: Medicaid patients’ longer hospitalization and higher hospital charge suggest disparity at the hospital treatment stage.     

Utilization of head CT during injury visits to United States emergency departments: 2012–2015

Introduction

Studies have shown increasing utilization of head computed tomography (CT) imaging of emergency department (ED) patients presenting with an injury-related visit. Multiple initiatives, including the Choosing Wisely? campaign and evidence-based clinical decision support based on validated decision rules, have targeted head CT use in patients with injuries. Therefore, we investigated national trends in the use of head CT during injury-related ED visits from 2012 to 2015.