HEALTH CARE EXPENDITURES ASSOCIATED WITH PERSISTENT EMERGENCY DEPARTMENT USE: A MULTI-STATE ANALYSIS OF MEDICAID BENEFICIARIES

Transcription

1 HEALTH CARE EXPENDITURES ASSOCIATED WITH PERSISTENT EMERGENCY DEPARTMENT USE: A MULTI-STATE ANALYSIS OF MEDICAID BENEFICIARIES Presented by Parul Agarwal, PhD MPH 1,2 Thomas K Bias, PhD 3 Usha Sambamoorthi, PhD 1 1 West Virginia University School of Pharmacy, Morgantown, WV 2 Institute of Healthcare Delivery Science, Mount Sinai Health Systems, NY 3 West Virginia University School of Public Health, Morgantown, WV

2 BACKGROUND Emergency Medical Treatment and Labor Act Changing role of Emergency Department (ED) ED use by - Uninsured - Insured Used for emergent and non-emergent conditions 1,2 ED use results in 3 - Fragmented care - Higher healthcare expenditures - Reduced quality of care 2

3 Background Increased ED visits in past two decades - 32% increase from 1997 to More than 130 million ED visits in Out of 354 million visits for acute care conditions that could have been managed by primary care providers one-third treated in EDs 6 Many individuals visit ED repeatedly 7 Provision of treatment in EDs is expensive as compared to other settings 8 3

4 From: Trends and Characteristics of US Emergency Department Visits, JAMA. 2010;304(6): doi: /jama ED visits increased from 9.6 million to 17.7 million among Medicaid enrollees Figure Legend: ED indicates emergency department. Error bars indicate 95% confidence intervals. Date of download: 12/12/2014 Copyright 2014 American Medical Association. All rights reserved. 4

5 Background Patient- and county-level factors are associated with increased ED visits 9,10 ED use by Medicaid beneficiaries received policy attention 11 Post Affordable Care Act more individuals enrolled in the Medicaid program 12 Expanded health insurance coverage without corresponding increase in the number of primary care providers may impact ED use Previous expansion of health insurance coverage revealed mixed findings 5

6 Study Rationale Frequent ED use for non-urgent and preventable conditions 1,2 Frequent ED use may be persistent with some individuals visiting EDs frequently every year 7 Understanding persistent ED use important for Medicaid Comprehensive research on subgroup differences in persistent ED users is lacking No study has examined the association between persistent ED use and healthcare expenditures excluding costs of ED visits 6

7 Objective Examine the patient- and county-level factors associated with persistent ED use and its impact on healthcare expenditures among adult fee-for-service (FFS) Medicaid beneficiaries. 7

8 Methods Study Design Retrospective observational study design Data from MD, OH, and WV for year 2009 & 2010 Index (calendar year 2009) and follow-up period (calendar year 2010) Persistent ED use was based on ED visits measured in both years Independent variables Dependent variable: Total healthcare expenditures Index (2009) Follow-up (2010) Persistent ED use 8

9 Methods Study Population years old Alive Men and non-pregnant women Not Medicare eligible FFS continuous enrollees Data Sources Medicaid Analytic extract files Area health resource file County health rankings data 9

10 Methods Medicaid Analytic extract (MAX) Files Personal Summary File Inpatient Claims File Other Therapy Claims File Prescription Drugs Claims File Examples of patient-level information Demographics, Medicaid eligibility, county federal information processing standard (FIPS) codes, Medicaid managed care enrollment, and Medicare eligibility status Hospital stays, dates of service, Medicaid payment, and the ICD-9-CM diagnosis and procedure codes Dates of service, types of service, Medicaid payment, ICD-9-CM, and CPT codes Date of prescription filled, days supplied, and national drug code (NDC), Medicaid payment 10

11 Methods Other Data Sources Area Health Resource File (AHRF) County Health Ranking Examples of county-level information Percent with college education, health professional shortage area, federally qualified health centers per 100,000 population and urgent care centers per 100,000 population, FIPS codes Obesity rate All datasets linked together using Federal Information Processing Standard (FIPS) codes. 11

12 Methods Dependent Variable 1) Persistent ED users versus Non-users No consensus on the number of ED visits that define frequent ED users Commonly used definition (i.e. 4 or more ED visits annually) 2) Total healthcare expenditures Payments made by Medicaid for outpatient, inpatient, and prescription drugs utilization ED expenditures were excluded Expenditures expressed in 2010 US dollars 12

13 Methods Independent Variables: Patient-level Variables Age Gender Race/Ethnicity Medicaid Eligibility Primary care use Poly-pharmacy Complex chronic illness Tobacco use Metro Categories 22-34, 35-44, 45-54, years Female, male Whites, African Americans, Hispanics, Other Races Cash eligibility, No cash eligibility, Medical eligibility, No medical eligibility None, fragmented, continuous Yes, No Presence of physical health conditions, presence of mental health conditions, presence of both physical and mental health conditions, none Yes tobacco use, No tobacco use Metro, non-metro 13

14 Methods Independent Variables: County-level Variables Education Unemployment Obesity Health Professional Shortage Area Hospitals with EDs Hospitals with psychiatric emergency services Rural health clinics Federally qualified health centers Community mental health centers Urgent care centers Categories County-level education rate County-level unemployment rate County-level obesity rate None, partial, complete shortage Number of hospitals with EDs/100,000 population Number of hospitals with psychiatric emergency services/100,000 population Number of rural health clinics/100,000 population Number of federally qualified health centers/100,000 population Number of community mental health centers/100,000 population Number of urgent care centers/100,000 population 14

15 Methods Statistical Analyses Define Characteristics of the study population Unadjusted differences between persistent ED users vs non-users Patient- and county-level factors associated with persistent ED use Association between healthcare expenditures and persistent ED use Methods Frequencies and percentages Chi-square tests of association Logistic regression Unadjusted and adjusted generalized linear models (GLM) with log link function and gamma distribution 15

16 Primary Care use Fragemented Continuous Complex chronic illness PHC MHC PHC & MHC None Poly-pharmacy Yes No Tobacco Use Yes No Row percentages Column percentages Characteristics of persistent ED users and inpatient use (N = 22,252) % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 55.60% Persistent ED users 2% Non-users Patient-level Factors 16

17 Adjusted Odds Ratios Factors associated with persistent ED use Patient- and County-level Factors 17

18 Mean Expenditures and Ratio of Means by Type of Healthcare Expenditures Non-users (N = 17,107) Persistent ED users (N = 5,145) Type of Expenditures Mean ($) SE Mean ($) SE Ratio of means Total*** 17, , Outpatient*** 13, , Prescription Drugs*** 4, , In Users Prescription Drugs*** 4, , Inpatient*** 10, , Note: Asterisks represent significant group differences between persistent ED users and non-users based on IPTW adjusted t-tests. SE = standard errors *** p<.001; **.001 < p <.01; *.01 < p <.05 ED expenditures excluded from total and outpatient 18

19 Type of Expenditures Total (without ED) Outpatient (without ED) Generalized Linear Models with Log Link Function By Type of Expenditures Prescription Drugs Intercept (SE) 8.68*** (0.62) 7.59*** (0.72) 7.61*** (0.35) Persistent ED Use -Beta (SE) Change ($) 0.78*** (0.06) 6, *** (0.06) *** (0.15) Note: SE = standard errors *** p<.001; **.001 < p <.01; *.01 < p <.05 19

20 Policy Implications Critical to explore ways to triage patients to other settings such as urgent care centers Need for policies, programs, and interventions that can meet the healthcare needs of persistent ED users One can speculate that coordinated care models may reduce persistent ED use and healthcare expenditures 20

21 Limitations & Strengths Limitations Administrative claims data are for billing purposes Could not measure some patient-level factors such as obesity or reasons for using ED Strengths Track repeated ED visits by an individual Differentiate between persistent ED users and non-users Information available on clinical diagnosis Availability of payment amount Use of county-level factors 21

22 Acknowledgements 22

23 References 1) Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a substitute for primary care? Issue brief. Nov 2000(433):1-5. 2) Oster A, Bindman AB. Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations. Medical care. Feb 2003;41(2): ) Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press; ) Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, Jama. Aug ;304(6): ) Weiss AJ, Wier LM, Stocks C, Blanchard J. Overview of Emergency Department Visits in the United States, 2011: Statistical Brief #174. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD) ) Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it's not at their doctor's office. Health Aff (Millwood). Sep 2010;29(9): ) Cook LJ, Knight S, Junkins EP, Jr., Mann NC, Dean JM, Olson LM. Repeat patients to the emergency department in a statewide database. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Mar 2004;11(3): ) Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff (Millwood). Sep 2010;29(9): ) Billings J, Raven MC. Dispelling an urban legend: frequent emergency department users have substantial burden of disease. Health Aff (Millwood). Dec 2013;32(12): ) Capp R, Rosenthal MS, Desai MM, et al. Characteristics of Medicaid enrollees with frequent ED use. The American journal of emergency medicine. Sep 2013;31(9): ) CMS, Medicaid Services HHS. Medicaid program; eligibility changes under the Affordable Care Act of Final rule, Interim final rule. Federal register. 2012;77(57): ) CMS. Medicaid & CHIP: April 2015 Monthly Applications, Eligibility Determinations and Enrollment Report. MD: Department of Health and Human Services Centers for Medicare & Medicaid Services; 30th Sept

24 THANK YOU! 24