Dataset Information

Emergency Department and Ambulatory Care Visits in the First Twelve Months of Coverage Under Medicaid Expansion: A Group-Based Trajectory Analysis.

ABSTRACT:

Study objective

More than 17 million people have gained health insurance coverage through the Patient Protection and Affordable Care Act's Medicaid expansion. Few studies have examined heterogeneity within the Medicaid expansion population. We do so based on time-varying patterns of emergency department (ED) and ambulatory care use, and characterize diagnoses associated with ED and ambulatory care visits to evaluate whether certain diagnoses predominate in individual trajectories.

Method

We used group-based multitrajectory modeling to jointly estimate trajectories of ambulatory care and ED utilization in the first 12 months of enrollment among Pennsylvania Medicaid expansion enrollees from 2015 to 2017.

Results

Among 601,877 expansion enrollees, we identified 6 distinct groups based on joint trajectories of ED and ambulatory care use. Mean ED use varied across groups from 3.4 to 48.7 visits per 100 enrollees in the first month and between 2.8 and 44.0 visits per 100 enrollees in month 12. Mean ambulatory visit rates varied from 0.0 to 179 visits per 100 enrollees in the first month and from 0.0 to 274 visits in month 12. Rates of ED visits did not change over time, but rates of ambulatory care visits increased by at least 50% among 4 groups during the study period. Groups varied on chronic condition diagnoses, including mental health and substance use disorders, as well as diagnoses associated with ambulatory care visits.

Conclusion

We found substantial variation in rates of ED and ambulatory care use across empirically defined subgroups of Medicaid expansion enrollees. We also identified heterogeneity among the diagnoses associated with these visits. This data-driven approach may be used to target resources to encourage efficient use of ED services and support engagement with ambulatory care clinicians.

SUBMITTER: Hollander MAG

PROVIDER: S-EPMC8238783 | biostudies-literature |

REPOSITORIES: biostudies-literature

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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.

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