Report dispels conventional wisdom on what drives Medicaid ED use

Washington Urgent or more serious medical problems are what prompt most nonelderly Medicaid patients visiting the emergency department to go there, underscoring a need for better access for those patients to primary care and specialty services, according to a recent study.

In 2008, more than half of Medicaid and privately insured patients visiting the ED had conditions that were categorized as emergent that needed immediate attention, or urgent that needed attention within an hour. Only about 10% of nonelderly Medicaid patient ED visits were for nonurgent symptoms, compared with about 7% for privately insured nonelderly people, the Center for Studying Health System Change reported in its study, released July 11.

But although they're showing up for some of the same reasons, nonelderly Medicaid patients are using EDs at higher rates than nonelderly privately insured patients, and at more than double the rate of adults with private insurance for all major diagnostic groups, including respiratory, digestive, musculoskeletal and nervous system diseases.

“Adults aged 21 to 64 with Medicaid also were three times as likely as privately insured adults to have visits for diagnoses indicating potentially complex needs from pregnancy and disabling conditions, such as cerebral palsy, cardiomyopathy and chronic hepatitis — 5.4 visits per 100 Medicaid enrollees versus 1.5 visits per 100 privately insured enrollees,” the study said.

“This certainly goes against conventional wisdom that Medicaid patients are using the ED for more routine-type visits,” said David Seaberg, MD, president of the American College of Emergency Physicians. The findings mainly relate to access, cementing the fact that Medicaid isn't a great payer, he said. “Even though these patients have Medicaid as insurance, the program still doesn't provide them great access to primary care and specialty care.”

The patients also on the whole are of lower socioeconomic status, may not be able to afford co-pays, or don't have the ability or time to get to doctors' offices, “and consequently they have poorer health, so when they get sick they have higher acuity,” Dr. Seaberg said.

Other physicians in the field also said the results weren't surprising. “Medicaid patients have always been coming in for emergent conditions and urgent conditions,” said Nathaniel Schlicher, MD, an emergency physician and associate medical director of Saint Joseph Medical Center in Tacoma, Wash.

ED use and crowding in general have been on the rise. An Annals of Emergency Medicine study published online June 20 found that the total time patients spent in the ED jumped nearly 30% from 2001 to 2008, increasing from 330 million to 417 million hours. The number of high-acuity patients also grew by 23% during this period.

Limited office resources a big factor

The HSC study said that while Medicaid patients typically aren't treating the ED as their primary care office, barriers that they face in accessing both primary and specialty care at the front end probably are contributing to high ED use among these patients. Only 53% of specialists in the U.S. were accepting all or most new Medicaid patients in 2008, for instance, compared with 87% accepting all or most new privately insured patients.

Limited resources at primary care offices “could make it impractical to diagnose and treat uncomplicated problems, even if symptoms are nonurgent,” according to the findings. “Only about one-third of primary care physicians serving a large percentage of adult Medicaid patients had x-ray equipment at their main practice in 2008, while less than half offered laboratory services.”

The report said, “Studies also have linked higher ED use by Medicaid enrollees whose primary care practices have fewer weekday evening hours or lack medical supplies to treat respiratory conditions like nebulizers and peak flow meters.”

In some instances, the ED may be the most appropriate venue of care for these types of patients even when the office is open, Dr. Seaberg said. Abdominal pain and chest pain, two major complaints often seen in the ED, are very difficult to evaluate in a primary care office, he said.

Better primary care access, however, could prevent patients with chronic diseases from having acute manifestations of their conditions, said Caroline Steinberg, vice president for trends analysis with the American Hospital Assn. “For example, the lack of access in the Medicaid population can mean people with asthma are not getting the drugs they need or the outpatient care they need, so they end up going to the emergency department because they've had an asthma attack that could have been prevented.”

William Golden, MD, an internist and professor of medicine and public health at the University of Arkansas for Medical Sciences, offered a slightly different perspective. Many smaller primary care practices do not offer 24/7 phone access or extended office hours, leaving Medicaid families with little choice but to use the ED for dealing with acute care issues that otherwise could be handled through the office, he said.

Still, a very small percentage of Medicaid patients are true “superusers” of the emergency department, he said. “Many of them have concomitant mental health or homelessness issues that drive their behavior. This subpopulation, however, creates an image for the entire Medicaid program,” said Dr. Golden, medical director at the Arkansas Dept. of Human Services and Medicaid.

The study's findings are useful in showing that Medicaid patients often do have truly urgent or emergent conditions in seeking ED care, said Glen Stream, MD, president of the American Academy of Family Physicians. But he questioned the timeliness of the report, noting that it was based on 2008 data. The HSC study was funded by the Robert Wood Johnson Foundation and based on the most recent available data from the National Hospital Ambulatory Medical Care Survey conducted by the Centers for Disease Control and Prevention.

The study highlighted patient-centered medical homes as a potential way to reduce ED use by providing more extended hours for Medicaid patients. Yet, “a lot of the initiatives to achieve patient-centered medical home transformation only kicked off in 2008,” Dr. Stream said.

Attempts to shift care could backfire

To address high ED use by Medicaid enrollees, states are looking at several approaches, such as encouraging primary care health professionals to improve access and chronic disease management, the survey stated.

Settings other than primary care that could more readily provide access, such as urgent care and retail clinics, are another possible solution to reducing ED use. It's not certain, however, how many of those clinics would take Medicaid patients, Steinberg said. “They're set up to provide ongoing care for patients, [and] that's a good option. But to the extent they're set up to do urgent, episodic care, I'm not sure how well that would work.”

Steinberg said many hospitals were making efforts to link up patients who come to the emergency department with sources of follow-up primary care.

States also are looking at the idea of increasing co-payments or refusing to pay for certain types of ED visits determined to be medically unnecessary, according to the HSC study. But recent evidence showed these co-payments are ineffective in reducing nonurgent ED visits by Medicaid enrollees. It also raises the concern that patients with truly urgent concerns would not get the care they needed.

Washington state earlier in 2012 was on the verge of implementing a policy under which Medicaid payment would have been denied for ED care given to patients diagnosed with one of about 500 conditions deemed by the state to be nonurgent. The policy had been scheduled to kick in April 1, but Gov. Chris Gregoire suspended it following protests by ACEP in the statehouse and the courts that it unfairly targeted low-income patients.

Instead, the state Legislature adopted an alternative plan endorsed by emergency physicians to improve coordination and quality of care, Tacoma, Wash., emergency physician Dr. Schlicher said. One of the plan's key elements will set up an integrated health care delivery exchange that will enable neighboring hospitals to track where patients have been admitted and how they've been using the ED, he said. This should drive down costs by helping to reduce unnecessary testing as well as track the small percentage of patients who may be using the ED to obtain narcotics, he said.