While non-elderly Medicaid patients do use the ED more than their privately insured counterparts, the majority of visits are for urgent or more serious medical problems, according to a national study from the Center for Studying Health System Change (HSC).
Based on evaluations of patients prior to and after treatment, the study found the following:
For emergent visits, or those needing immediate attention, nonelderly Medicaid patients were seen in EDs at the rate of 5.6 visits per 100 enrollees vs. 3.6 visits per 100 privately insured people.
For urgent visits, or those needing attention within an hour, the rate for nonelderly people covered by Medicaid was 18.1 visits per 100 enrollees vs. 9.6 visits per 100 privately insured people.
For semi-urgent visits, or those needing care in 1 to 2 hours, the Medicaid rate was 10.4 visits per 100 nonelderly enrollees vs. 5.5 visits for privately insured people.
While these findings may be contrary to popular opinion, they aren't a surprise to emergency physicians, says Dr. David C. Seaberg, president of the American College of Emergency Physicians.
"People who go to the emergency department, for the most part, need to be there," he says, "because they tend to be sicker." Among Medicaid patients there is a higher prevalence of chronic disease and disability than among people with private insurance, he said. And for those Medicaid patients with chronic disease and urgent healthcare needs, the ED is probably the best place for them to receive care, because the hospital has the right staff and equipment to treat them quickly and appropriately.
And concentrating on limiting ER access to non-urgent patients won’t necessarily do much to decrease healthcare costs overall, according to a paper published in the Annals of Emergency Medicine.
“The focus on non-urgent ER visits distracts from the potential savings that do exist in the area of hospital admissions,” said lead study author Peter Smulowitz, MD, FACEP, of Beth Israel Deaconess Medical Center in Boston, MA. “Emergency department patients are responsible for about half of all hospital admissions, and those admissions account for about 15 percent of all healthcare expenses. Many patients are admitted to the hospital from the ER either because the gaps in the rest of the healthcare system leave patients without other good care options, or because a fragmented system has failed to care for their complex chronic disease.”
Dividing ED visits into three categories – emergencies, intermediate/complex conditions and minor injuries/illnesses – researchers assessed the potential cost savings for each. While savings were minimal for minor injuries and illnesses and emergencies, for intermediate/complex conditions:
The potential savings amounted to a maximum of 2.5 percent of all healthcare spending, which Dr. Smulowitz attributed mostly to reduced hospital admissions. The expanded use of observation units in emergency departments offers one opportunity to reduce costs by reducing hospital admissions.
Collaboration between emergency physicians, case managers and community-based services could also allow for patients to be cared for at home or in short-term facilities rather than being hospitalized because of a lack of safe alternative options, he continues.
Collaboration was key to the success of a statewide quality improvement project aimed at reducing avoidable emergency room visits among Medicaid patients in California, which created a unique partnership between L.A. Care Health Plan, the country's largest Medicaid managed care plan, and Children's Hospital Los Angeles. Many patients, particularly in the Medicaid population, do not completely understand the primary care process or know of options when faced with medical problems. Providing them with information and options is crucial towards redirecting them to the proper medical avenue, explained Laura Linebach, director of quality improvement at L.A. Care Health Plan, who gave a recent webinar at the Healthcare Intelligence Network, Reducing Avoidable Medicaid ER Visits With a Community Partnership Approach. In addition to launching a state-wide public health campaign including brochures and educational packets, a nurse advice line was very successful:
“The nurse advice line provides 24-hour, 7 day a week telephone access to a registered nurse. Nurses advise members in their preferred language about the setting to receive care: PCP, home, ER, or urgent care. Preferred language is addressed by use of a bilingual nurse or interpreter services. But getting our diverse population to trust and call the line is difficult. However, we found that those members with the pre-intent of going to the emergency room when they called the nurse advice line and who would triage with the nurse advice line with advice not to visit the ER, 80 percent of those complied and did not go to the ER. We studied any visit within 48 hours after the nurse advice line call.”
There are conditions that can be treated outside of the ER, in particular, two diagnoses with the greatest potential to reduce ED use for both nonelderly people covered by Medicaid and private insurance if access to appropriate alternative care settings existed, researchers at HSC said. First, acute respiratory and other common infections in children, and second, injuries among all nonelderly people.
Diagnoses of acute respiratory and other common infections in children and injuries accounted for more visits by privately insured children aged 0 to 12 (60 percent) than those children covered by Medicaid: (53 percent). Researchers suggest that while some infections and injuries will be too serious to treat elsewhere, lower-cost settings that can provide a moderate intensity of care and urgent response time likely could reduce emergency department use.
The study goes on to state that
"…primary care settings may not be a practical solution for all cases. Many primary care offices cannot see patients quickly enough to manage urgent problems or do not have the right equipment at the practice. Alternative care settings would need to provide prompt care for urgent cases and have appropriate services and equipment to diagnose and treat minor cases,” the study concludes.