Reason For Medicaid ED Visits Same As Privately Insured

By  //  July 16, 2012

Healthcare Policy Research and Analysis

A new study released last week by the Center for Studying Health System Change (HSC) argues that, contrary to popular perception among policy makers and healthcare providers, most visits to emergency departments by Medicaid patients are for urgent care, and basically for the same reasons as their privately insured peer group. 

Individuals With Medicaid, Private Insurance Use ED For Same Reasons

The survey found that three-quarters of the Medicaid visits were categorized as emergent, urgent or semi-urgent, while among those with private coverage, the number stood at 78 percent. Ten percent of non-elderly Medicaid patients’ visits to EDs were for non-urgent care, compared with 7 percent for non-elderly patients with private insurance.

The report states that, “Contrary to the conventional wisdom that Medicaid enrollees often use emergency departments for routine care, non-urgent visits explain only a small portion of nonelderly Medicaid enrollees’ higher emergency department use.”

Non-partisan Research and Analysis

HSC is a non-partisan organization based in Washington D.C. that designs and conducts health policy research and analysis focused on the U.S. health care system to inform the thinking and decisions of policy makers in government and private industry. HSC provides targeted research and analysis that can contribute to better health policy in the key policy areas of health insurance coverage and cost, access to care, quality and care delivery and healthcare markets.

Poor Use the ED Almost Twice As Much As The Privately Insured

The HSC study, which relied on data from the National Hospital Ambulatory Medical Care Survey, a federal database that tracks trips to emergency departments across the country, did show that

Medicaid patients use the ED for the same reasons, but more frequently than the privately insured. (Shutterstock Image)

Medicaid patients do use EDs at significantly higher rates than privately insured patients with 45.8 ED visits per 100 Medicaid enrollees under 65 compared with 24 visits per 100 by privately insured patients under 65. However, the study clearly shows that most of the difference in utilization came from more ED use by Medicaid patients with urgent and semi-urgent symptoms.

“If you picked a Medicaid recipient and a privately insured patient out of an ED waiting room and asked them both why they were there, the likelihood that they described symptoms we would call non-urgent is pretty similar,” HSC Senior Researcher Emily Carrier, M.D. told Reuters.

Findings Suggest Challenges For Medicaid Members In Receiving Routine Healthcare

“Most of the difference in emergency department use between nonelderly Medicaid and privately insured patients results from more ED use by Medicaid patients for urgent and semi-urgent symptoms that need prompt medical attention,” said Carrier, and co-authors Anna S. Sommers, Ph.D., a former HSC senior researcher; and Ellyn R. Boukus, M.A., an HSC health research analyst.

Proponents of the Patient Protection and Affordable Care Act (PPACA), which has provisions to significantly increase access to health insurance coverage, partly by expanding Medicaid in 2014 to insure more low-income Americans, suggest that Medicaid coverage would help them receive routine medical care and avoid costly ED visits.

Better management of the Medicaid population health wellness and maintenance is imperative.

However, the HSC authors indicate that limited access to primary care, purported to play a significant part in higher Medicaid utilization of the ED, does not have as significant an impact as previously thought, and that fixing the primary care problem might not be the practical solution in all cases because practices cannot see patients quickly enough for urgent problems or do not have the appropriate equipment.

The study did suggest using alternative settings, such as urgent care centers and patient-centered medical homes, and developing new models of better population health wellness and maintenance.

Researchers Call For Hospitals To Reevaluate ED Use Marketing Strategies 

The study also addresses the question: If ED crowding and high costs are not directly related to poor patients seeking routine care, then what are the causes?  The study authors suggest that most crowding and associated cost inefficiencies result from emergency patients admitted to the hospital but waiting for an inpatient bed–ED boarding–not a high volume of non-urgent ED visits.

Patients 'boarded" in the hall of a busy ED waiting for a bed on the hospital units.

“Some hospitals actively seek to draw patients with minor problems to their emergency departments by advertising short wait times on billboards and through mobile phone applications,” the study states. “Broader payment reforms, such as accountable care organizations, that move away from fee-for-service payment could alter incentives for hospitals to market their EDs as aggressively and prompt greater development of lower-cost settings that can deal with urgent medical needs.”

This study strongly suggests that there are clearly opportunities for policy makers and providers to develop less-costly care options than emergency departments for both non-elderly Medicaid and privately insured patients.