Dataset Information

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

ABSTRACT:

Objective

To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits.

Data sources

West Virginia Medicaid enrollment and claims data from 2005 to 2010.

Study design

We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps.

Data collection

Data were obtained from the West Virginia Bureau for Medical Services.

Principal findings

We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan.

SUBMITTER: Gurley-Calvez T

PROVIDER: S-EPMC4946032 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

Gurley-Calvez Tami T Kenney Genevieve M GM Simon Kosali I KI Wissoker Douglas D

Health services research 20160114 4

<h4>Objective</h4>To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits.<h4>Data sources</h4>West Virginia Medicaid enrollment and claims data from 2005 to 2010.<h4>Study design</h4>We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in ...[more]

PMID: 26762205

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Project description:ImportanceRelatively little is known about the association of the Medicaid eligibility expansion under the Patient Protection and Affordable Care Act with emergency department (ED) visits categorized by medical urgency.ObjectiveTo estimate the association between state Medicaid expansions and ED visits by the urgency of presenting conditions.Design, setting, and participantsThis cross-sectional study used the Healthcare Cost and Utilization Project State Emergency Department Databases from January 2011 to December 2017 for 2 states that expanded Medicaid in 2014 (New York and Massachusetts) and 2 states that did not (Florida and Georgia). Difference-in-differences regression models were used to estimate the changes in ED visits overall and further stratified by the urgency of the conditions using an updated version of the New York University ED algorithm between the states that expanded Medicaid and those that did not, before and after the expansion. Data were analyzed between June 7 and December 12, 2021.ExposureState-level Medicaid eligibility expansion.Main outcomes and measuresEmergency department visits per 1000 population overall and stratified by medical urgency of the conditions.ResultsIn total, 80.6 million ED visits by 26.0 million individuals were analyzed. Emergency department visits were concentrated among women (59.3%), non-Hispanic Black individuals (28.3%), non-Hispanic White individuals (47.8%), and those aged 18 to 34 years (47.5%) and 35 to 44 years (20.4%). The rates of ED visits increased by a mean of 2.4 visits in nonexpansion states and decreased by a mean of 2.2 visits in expansion states after 2014, resulting in a significant regression-adjusted decrease of 4.7 visits per 1000 population (95% CI, -7.7 to -1.5; P = .003) in expansion states. Most of this decrease was associated with decreases in ED visits by conditions classified as not emergent (-1.5 visits; 95% CI, -2.4 to -0.7; P < .001), primary care treatable (-1.1 visits; 95% CI, -1.6 to -0.5; P < .001), and potentially preventable (-0.3 visits; 95% CI, -0.5 to -0.1; P = .02). No significant changes were observed for ED visits related to injuries and conditions classified as not preventable (-1.4; 95% CI, -3.1 to 0.3; P = .10), as well as for substance use and mental health disorders (0.0; 95% CI, -0.2 to 0.2; P = .94).Conclusions and relevanceThe findings of this study suggest that Medicaid expansion was associated with decreases in ED visits, for which decreases in ED visits for less medically emergent ED conditions may have been a factor.

Project description:IntroductionThe purpose of the study is to investigate how community-based organizations perceive Medicaid policy changes to address the social determinants of health.MethodsThis study included 46 key informant interviews, representing 44 community-based organizations across Massachusetts conducted from September 2017 to March 2018. The interviews were designed to collect community-based organizations' perceptions of Medicaid policy changes. An Advisory Board was empaneled for feedback on data collection and analysis. Massachusetts was chosen as a study site in light of explicit policy efforts to incentivize healthcare organizations to take a more active role in social determinants of health, most notably through the creation of Medicaid Accountable Care Organizations.ResultsThe community-based organizations expressed optimism about future partnerships with healthcare organizations. This optimism existed alongside the recognition that healthcare organizations and community-based organizations can have conflicting agendas, including misaligned outcomes of interest and timelines. Community-based organizations struggled to define a clear strategy for partnership in the face of incomplete information about how the final Medicaid redesign would proceed and what healthcare providers would be looking for in a partner.ConclusionsChanges to Medicaid policy can catalyze interest in partnership between healthcare organizations and community-based organizations. To minimize the impact of conflicting agendas, policymakers and healthcare leadership should ensure community-based organizations are part of strategy development and social service program implementation.Supplement informationThis article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Project description:BACKGROUND:West Virginia is a largely rural state with strong ties of kinship, mutual systems of support and charitable giving. At the same time, wealth inequalities are extreme and the state's drug overdose fatality rate stands above all others in the USA at 51.5/100,000 in 2018, largely opioid-related. In recent years, harm reduction services have been active in the state but in 2018 Charleston's needle and syringe program was forced to close. This paper considers the risk environment in which the state's drug-related loss of life, and those attempting to prevent it, exist. METHODS:This rapid ethnographic study involved semi-structured interviews (n?=?21), observation and video recordings of injection sequences (n?=?5), initially recruiting people who inject heroin/fentanyl (PWIH) at the Charleston needle and syringe program. Snowball sampling led the research team to surrounding towns in southern West Virginia. Telephone interviews (n?=?2) with individuals involved in service provision were also carried out. RESULTS:PWIH in southern West Virginia described an often unsupportive, at times hostile risk environment that may increase the risk of overdose fatalities. Negative experiences, including from some emergency responders, and fears of punitive legal consequences from calling these services may deter PWIH from seeking essential help. Compassion fatigue and burnout may play a part in this, along with resentment regarding high demands placed by the overdose crisis on impoverished state resources. We also found low levels of knowledge about safe injection practices among PWIH. CONCLUSIONS:Hostility faced by PWIH may increase their risk of overdose fatalities, injection-related injury and the risk of HIV and hepatitis C transmission by deterring help-seeking and limiting the range of harm reduction services provided locally. Greater provision of overdose prevention education and naloxone for peer distribution could help PWIH to reverse overdoses while alleviating the burden on emergency services. Although essential for reducing mortality, measures that address drug use alone are not enough to safeguard longer-term public health. The new wave of psychostimulant-related deaths underline the urgency of addressing the deeper causes that feed high-risk patterns of drug use beyond drugs and drug use.

Project description:OBJECTIVES:Policymakers have increasingly focused on emergency department (ED) utilization for primary care-treatable conditions as a potentially avoidable source of rising health care costs. The objective was to determine the association of health insurance type and arrival time, as indicators of limited availability of primary care, with primary care-treatable classification of ED visits. METHODS:This was a retrospective analysis of a nationally representative sample of 241,167 ED visits from the 1997 to 2009 National Hospital Ambulatory Medical Care Surveys (NHAMCS). Probabilities of ED visits being primary care-treatable were categorized based on the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The association of health insurance type and arrival time was determined with the average probability of the primary diagnosis being primary care-treatable using multivariable linear regression. RESULTS:Compared to privately insured visits, Medicaid visits had a 1.7% (95% confidence interval [CI] = 1.2% to 2.2%) and uninsured visits a 2.4% (95% CI = 1.9% to 3.0%) higher probability of primary care-treatable classification, while Medicare visits had a 1.4% (95% CI = 0.7% to 2.0%) lower probability during the overall study period. Compared to business hours, weekend visits had a 1.5% (95% CI = 1.0% to 2.0%) higher probability of being primary care-treatable during the overall study period. From 1997 to 2009, the overall adjusted probability of ED visits being primary care-treatable increased by 0.19% (95% CI = 0.10 to 0.28) per year. This probability increased at a rate of 0.52% per year for Medicare visits (95% CI = 0.38% to 0.65%), more than double that of Medicaid visits (0.25% per year, 95% CI = 0.13% to 0.37%). By contrast, there was no significant change from 1997 to 2009 in the average probability of ED visits being primary care-treatable by privately insured (0.05% per year, 95% CI = -0.07 to 0.16) or uninsured (0.00% per year, 95% CI = -0.12 to 0.13) individuals. CONCLUSIONS:These findings add to prior work that implicates insurance type and arrival time in the variation of primary care-treatable ED visits. Although primary care-treatable classification of ED visits was most associated with uninsured or Medicaid visits, this classification increased most rapidly among Medicare visits during the study period.

Dataset Information

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

Objective

Data sources

Study design

Data collection

Principal findings

Publications

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

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