Only 10% of Medicaid Enrollees' ED Use Is Unnecessary

Marcia Frellick

August 11, 2014

Medicaid enrollees use emergency departments (EDs) more often than privately insured and uninsured people, but that use accounts for just 4% of total Medicaid spending, a literature review by the Medicaid and CHIP Payment and Access Commission (MACPAC) indicates.

The review also found that only 10% of ED visits by nonelderly patients are for nonurgent reasons, which compares with the rate of use by privately insured patients. MACPAC researchers reviewed recent studies on ED use and did not find consistent links between Medicaid status and disproportionate ED use for nonemergency situations.

Concerns flared after a report published in Science in January indicated that Oregon's 2008 Medicaid expansion to low-income adults resulted in Medicaid enrollees using EDs 40% more than the uninsured, leading to fears that Medicaid expansion in other states under the Affordable Care Act (ACA) would result in ballooning costs and ED overcrowding.

The advantage of a literature review is that researchers can examine results from a spectrum of studies and get a broader context over time, said Dylan Roby, PhD, director of health economics and evaluation research at the University of California-Los Angeles Center for Health Policy Research.

He told Medscape Medical News that in contrast to the most recent Oregon study, 2 previous studies of the Oregon expansion, as noted in the MACPAC report, found no major change in ED use for enrollees.

But public perception that more access to care by more Medicaid enrollees will result in expensive ED use, along with other common beliefs about Medicaid, led MACPAC to review recent studies to separate myth from reality.

Definitions Differ on "Avoidable" Care

MACPAC found that one factor that leads to misconceptions of overuse is the definition of when visits are "avoidable" or "preventable."

Anne Schwartz, PhD, MACPAC's executive director, told Medscape Medical News that the problem with categorizing care as unnecessary is that evaluation comes in hindsight.

"People who present in the emergency room — a child with high fever or an adult with chest pains — don't know at that time that that isn't something they should be worried about.... You can't always tell prospectively if that care could have waited until the next morning. You would need a physician assessment in many cases and if you don't have another place to go to, where else would you go but the ED?" she said.

MACPAC did find that the public perception that Medicaid enrollees use the ED because they have trouble getting in to see another provider is often valid.

Nearly all enrollees report having a usual place of care, the MACPAC brief said, but still about 1 in 3 adults and 13% of child enrollees report difficulty or delays in getting primary care. Medicaid enrollees reported problems including trouble reaching physicians by phone, delays in getting an appointment, language barriers, and lack of transportation. Medicaid covers a disproportionate number of disabled people, and barriers to access include facilities that lack appropriate physical access and improperly trained staff, factors that also can lead to ED use.

Effect of Expansions Unclear

As to whether Medicaid expansion would lead to more ED use nationally, MACPAC found insufficient evidence to support that claim and concluded that experiences differ state by state according to capacity of safety net providers, number of newly eligible, and design of delivery systems.

Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, says early short-term looks at whether expanding Medicaid means more use of EDs may be misleading because people who have never had insurance have pent-up needs. They want to get them taken care of quickly and all in one place instead of taking time off work for an appointment, going to a different place to get tests, then scheduling another appointment to go over lab results. Over time, as payment models for primary care physicians improve and enrollees solidify relationships with primary care doctors, those spikes in need will likely level out, he told Medscape Medical News.

Evidence about effects of the ACA and Medicaid expansion on ED use will need to be followed over time, but the primary focus should instead be on avoiding inpatient stays, UCLA's Dr. Roby said.

"An ER, even though it's more expensive than an urgent-care visit or a primary care visit, isn't that expensive when compared to an inpatient stay, so the real money-saver out there will be finding a way to keep people out of the hospital," he said.

MACPAC is a nonpartisan, federal agency that provides policy and data analysis on Medicaid and CHIP to Congress.

Dr. Schwartz and Dr. Miller have disclosed no relevant financial relationships. Dr. Roby is part of a University of California team that has an open-ended Task Order contract with MACPAC. However, he has not participated in any that were funded, and was specifically not involved with the research cited in the current report.

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