Dataset Information

Out-of-Network Emergency Department Use among Managed Medicaid Beneficiaries.

ABSTRACT: Out-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.Enrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.We analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).We extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.Of 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.There are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity.

SUBMITTER: Raven MC

PROVIDER: S-EPMC5682123 | biostudies-other | 2017 Dec

REPOSITORIES: biostudies-other

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Out-of-Network Emergency Department Use among Managed Medicaid Beneficiaries.

Raven Maria C MC Guzman David D Chen Alice H AH Kornak John J Kushel Margot M

Health services research 20161111 6

<h4>Objective</h4>Out-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.<h4>Data sources and study setting</h4>Enrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.<h4>Study design</h4>We analyzed the ...[more]

PMID: 27861836

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Project description:High unemployment during the 2007-2009 Great Recession and eligibility expansions have increased the size and cost of Medicaid. To provide states with flexibility in administering the program while containing costs, the Deficit Reduction Act of 2005 (DRA) gave states the authority to impose cost-sharing strategies, including emergency department (ED) copayments for nonurgent visits. To our knowledge, there has been no previous longitudinal analysis of the effect of the DRA on health care utilization outcomes for Medicaid beneficiaries.To evaluate the effect of the DRA, which allowed states to enforce ED copayments for nonurgent visits, on ED utilization among Medicaid beneficiaries and to compare the effect among beneficiaries living in states that did and did not adopt ED copayments.A difference-in-difference quasi-experimental approach was used to compare trends in ED use among Medicaid beneficiaries from January 2001 to December 2010. Eight states with ED copayments for nonurgent ED visits (copayment states) were compared with 10 states with zero ED copayments (control states). The study cohort was the population of individuals 19 to 64 years old enrolled in Medicaid for a full calendar year as collected by the Medical Expenditure Panel Survey, a nationally representative survey of noninstitutionalized US civilians. The cohort consisted of 3122 adult Medicaid recipients in copayment states and 7433 adult Medicaid recipients in control states.The main exposure was the copayment enforcement authority of the DRA. The study controlled for sex, age, race, marital status, income relative to the federal poverty level, educational level, and self-reported health status.The primary outcome of this study was the change in the rate of ED utilization following the DRA. Additional outcomes included changes in the rate of outpatient medical provider visits and inpatient length of stay. Visits were not coded according to urgency, which prevented us from examining only nonurgent ED use.Estimates from a zero-inflated Poisson regression model detected no statistically significant change in annual ED admissions per Medicaid enrollee (change, 0.05; 95% CI, -0.05 to 0.16) in copayment states compared with control states following the DRA. There was also no change in the rate of outpatient medical provider visits (change, 0.02; 95% CI, -0.31 to 0.35) or in annual inpatient days (change, 0.13; 95% CI, -0.31 to 0.57) per Medicaid enrollee.Granting states permission to collect copayments for nonurgent visits under the DRA did not significantly change ED or outpatient medical provider use among Medicaid beneficiaries.

Project description:ObjectiveTo evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care ("carve-in group") versus a Medicaid entity that separated this financing ("carve-out group").Data sources/study settingMedicaid claims data from two Medicaid entities in the Portland, Oregon tri-county area in 2016.Study designIn this cross-sectional study, we compared differences across enrollees in the carve-in versus carve-out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits.Data collectionWe used Medicaid claims, including adults with at least 9 months of enrollment.Principal findingsThe study population included 45,786 adults with mental health conditions. Relative to the carve-out group, individuals in the carve-in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve-in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve-in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees).ConclusionsFinancial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors.

Dataset Information

Out-of-Network Emergency Department Use among Managed Medicaid Beneficiaries.

Publications

Out-of-Network Emergency Department Use among Managed Medicaid Beneficiaries.

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