Emergency Room Use by Individuals with Disabilities Enrolled in Marylands HealthChoice Program

1
Emergency Room Use byIndividuals with
Disabilities Enrolled in Marylands HealthChoice
Program

• September 25, 2008
• Prepared for the
• Maryland Medicaid Advisory Committee

2
Why Study Emergency Room Use?

• The ER is an inappropriate setting for routine
  primary and specialty care.
• Use of the ER for non-emergency treatment taxes
  its capacity and may delay treatment for patients
  who are seriously ill or injured.
• Reliance on the ER as a medical home runs counter
  to care continuity and makes delivery of
  preventive care less likely.
• ER use is expensive.

3
Study Objectives

• Profile the use of ER services among non-elderly
  HealthChoice enrollees, with an emphasis on
  enrollees with disabilities.
• Estimate the rate of potentially avoidable ER
  use.
• Identify factors associated with frequent ER
  utilization.

4
Study Design

• Study period calendar year (CY) 2006.
• Data source HealthChoice eligibility files,
  Maryland Medicaid claims, and encounter data.
• The cohort consists of any HealthChoice enrollees
  who had any period of MCO enrollment in CY 2006.
• The definition of an ER visit includes both
  visits that resulted in an inpatient admission
  and visits that did not.
• Logistic regression was employed to model the
  likelihood of an ER visit during the study period.

5
Why Focus on HealthChoice Enrollees with
Disabilities?
6
Enrollees with disabilities made up 12 of the
HealthChoice population but accounted for 28 of
ER visits in the HealthChoice program.
-6-
7
About 45 of enrollees with disabilities visited
the ER at least once in CY 2006.
8
Of all enrollees who had an ER visit, those with
disabilities had the highest average number of
visits (3.3 visits per user).
9
ER visits by enrollees with disabilities were
more likely to result in an inpatient admission.
10

• Demographic Characteristics of ER Users among
  Enrollees with Disabilities

11
African-American and White enrollees with
disabilities were more likely than other
racial/ethnic groups to use the ER.

• In CY 2006
• 92 percent of HealthChoice enrollees with
  disabilities were either African American (57)
  or White (35).
• They also had the highest ER use rate 3.3 visits
  per user for African Americans and 3.4 for Whites.

12
Enrollees in Baltimore City were more likely than
enrollees in any other region of the state to
visit the ER.

• Enrollees with disabilities residing in Baltimore
  City had the highest ER utilization rate (3.6
  visits per user).
• Southern Maryland and Washington suburbs had the
  lowest rate of ER visits (2.8).
• Overall, HealthChoice enrollees in the disabled
  coverage group averaged 3.3 ER visits per user.

13
Older enrollees with disabilities were more
likely than those aged 18 and under to visit the
ER.
14

• Estimating Appropriate ER Utilization

15
ER use does not appear to increase on weekends.
16
Compared to other HealthChoice coverage groups,
enrollees with disabilities are more likely to
access ambulatory care before and after an ER
visit.

• 58 of ER visits by enrollees with disabilities
  did not have an ambulatory care visit within 30
  days before going to the ER (compared to 63 of
  ER visits by enrollees in other HealthChoice
  coverage groups).
• 52 of ER visits by enrollees with disabilities
  did not have an ambulatory care visit within 30
  days after having an ER visit (compared to 54
  of ER visits by enrollees in other HealthChoice
  coverage groups).

17
Methods of Identifying Potentially Avoidable ER
Visits

• CPT procedure codes as a crude indicator of
  potentially preventable ER visits.
• Methodology developed by researchers and
  clinicians at NYU Center for Health and Public
  Service Research.

18
About 55 of ER visits by enrollees with
disabilities are self-limited or minor
(compared to 66 of ER visits by all other
HealthChoice coverage groups).
-18-
19
Using the NYU algorithm, approximately 38.6 of
ER visits by enrollees with disabilities were
considered potentially avoidable (compared to
55.8 of ER visits for all the other HealthChoice
coverage groups).

• Non-emergent - The patient's initial complaint,
  presenting symptoms, vital signs, medical
  history, and age indicated that immediate medical
  care was not required within 12 hours
• Emergent/Primary Care Treatable - Based on
  information in the record, treatment was required
  within 12 hours, but care could have been
  provided effectively and safely in a primary care
  setting. The complaint did not require continuous
  observation, and no procedures were performed or
  resources used that are not available in a
  primary care setting (e.g., CAT scan or certain
  lab tests)
• Emergent - ED Care Needed - Preventable/Avoidable
  - Emergency department care was required based on
  the complaint or procedures performed/resources
  used, but the emergent nature of the condition
  was potentially preventable/avoidable if timely
  and effective ambulatory care had been received
  during the episode of illness (e.g., the
  flare-ups of asthma, diabetes, congestive heart
  failure, etc.)
• Emergent - ED Care Needed - Not
  Preventable/Avoidable - Emergency department care
  was required and ambulatory care treatment could
  not have prevented the condition (e.g., trauma,
  appendicitis, myocardial infarction, etc.)

20
Predictors of frequent ER use among enrollees
with disabilities.

• The following characteristics were associated
  with frequent ER use (5 or more visits in CY
  2006)
• Age 19-64
• Gender Female
• Race/ethnicity Whites and African Americans
• Location of residency Baltimore City

21
Limitations

• Study relies on administrative data only.
• No information on time of day ER visit occurred
  the time variable would indicate whether
  physician offices were closed at time of ER use.

22
Conclusion

• Enrollees with disabilities are more likely than
  other HealthChoice enrollees to use ER services.
• However, enrollees with disabilities
• Have the lowest rate of primary-care sensitive
  (potentially preventable) ER visits among
  HealthChoice coverage groups
• Have the highest rate of ER visits that lead to
  an inpatient admission, which suggests their ER
  utilization may be more appropriate than that
  of other HealthChoice populations 

23
About The Hilltop Institute

• The Hilltop Institute at the University of
  Maryland, Baltimore County (UMBC) is a nationally
  recognized research center dedicated to improving
  the health and social outcomes of vulnerable
  populations. Hilltop conducts research, analysis,
  and evaluation on behalf of government agencies,
  foundations, and other non-profit organizations
  at the national, state, and local levels.

24
Contact Information
David Idala Research Analyst The Hilltop
Institute University of Maryland, Baltimore
County (UMBC) 410.455.6296 didala_at_hilltop.umbc.edu
www.hilltopinstitute.org