Medicaid cuts spike ED use, uninsured hospitalizations
Medicaid cuts in Oregon were followed by increases in both hospital emergency department (ED) use and hospitalization of the uninsured. A study published online April 17, 2008, in the Annals of Emergency Medicine says federal legislation facilitating similar Medicaid changes in other states may lead to higher ED use and hospitalizations elsewhere.
Faced with a budget crisis due to an economic recession, Oregon introduced substantial changes to the Oregon Health Plan benefit package that were implemented in February and March 2003. Some 300,000 residents who met federally mandated Medicaid eligibility criteria were not affected. But residents in the Oregon Health Plan expansion program (generally childless adults with incomes below the federal poverty level) were affected by stricter enforcement of premiums of $6 to $12 per person per month, with forced disenrollment if premiums were not paid monthly. The researchers say the immediate effect of the stricter payment policy was that expansion program enrollment dropped from 103,000 in 2002 to some 51,000 by late 2003.
In addition, copayments were implemented for most services, including $5 for a primary care visit, $50 for an ED visit, and $250 for a hospitalization. While primary care providers were authorized to refuse care to patients who could not afford the copayments, EDs are required by federal law to provide a medical screening examination and thus did not have the option to refuse service.
Oregon Health Plan expansion enrollees also faced a reduction in the scope of covered services, including elimination of outpatient mental health and chemical dependency coverage.
The researchers say the effect of the cuts on ED use had been uncertain. "One might expect decreased ED use by patients losing Medicaid coverage because ED utilization rates by the uninsured are lower than rates for Medicaid enrollees and because poor patients respond to the risk of increased out-of-pocket costs by reducing ED use," they say. "On the other hand, patients with worse access to primary care are more likely to use EDs for primary care-treatable conditions and for emergencies caused by exacerbation of inadequately treated chronic diseases." Thus, the study's purpose was to evaluate the effect of the Oregon Health Plan changes on ED use in a representative sample of Oregon EDs before vs. after the Oregon Health Plan cutbacks to determine the change in payer mix.
Participating EDs provided data on 2,680,954 ED visits by Oregon residents. Individual ED patient volumes during the last 12 months ranged from 6,435 to 70,850 per year. There was a slight decrease in patient volumes throughout the study period.
Immediately after the date of the Oregon Health Plan cutbacks, there was an abrupt and sustained increase in ED visits by the uninsured, from 6,682 per month in 2002 (12.5% of visits) to 9,058 visits per month (17.3% of visits) in 2004, the report says. ED visits per month by Oregon Health Plan enrollees decreased beginning around the March 2003 date of the Oregon Health Plan policy changes (most likely attributable to Oregon's increasing unemployment rate during the period and the resultant loss in employer-sponsored insurance.
The report says the abrupt 20% adjusted increase in uninsured ED visits immediately after the Oregon Health Plan cutbacks is clearly seen and strongly suggests that much of the increase in uninsured ED visits is attributable to the Oregon Health Plan cutbacks.
"A 15% cutback in the Oregon Health Plan enrollment led to a 20% increase in the number of uninsured patients visiting the emergency department, which is a disturbing increase," said study author Robert Lowe, MD, director of the Oregon Health and Science University Center for Policy and Research in Emergency Medicine. "Equally disturbing is the enormous increase in emergency department visits related to alcohol, drug dependencies, and psychiatric illnesses, which are likely due to the concurrent cutbacks in mental health and drug treatment services by the Oregon Health Plan. And emergency hospitalizations rose by 50% for uninsured patients, while emergency hospitalization rates for the other groups remained about the same, suggesting that after the cutbacks uninsured patients were sicker overall when they came to the emergency department."
The effect's magnitude was even larger for behavioral health conditions, with an 82% adjusted increase in alcohol-related visits by uninsured persons and more than doubling of the adjusted number of drug-related and other psychiatric visits. "That the increase in uninsured visits was observed in all 26 emergency departments argues against artifactual causes such as a change in data systems in one hospital," the researchers say.
The researchers caution the study cannot distinguish between two possible explanations for the increase in uninsured ED visits: 1) whether the rate of ED use by uninsured patients changed; or 2) whether there was merely an increase in the number of uninsured Oregonians. However, they say, each possibility has important implications.
If the rate of ED use by Oregon's uninsured increased, it would suggest worsened access to medical care outside the ED because population groups with impaired access to traditional sources of primary care use EDs more frequently. If the rate of ED use by the uninsured remained constant as the number of uninsured increased, the increased number of uninsured ED patients affects the medical care delivery system as an increasing burden of uncompensated care for hospitals.
The analysis found that Oregon hospitals experienced an increase in charges for uncompensated care from $256 million in 2002 to $509 million in 2004, suggesting that the changes in Oregon's EDs mirrored the effect of the Oregon Health Plan cutbacks on inpatient care.
The researchers say the large uncompensated care burdens may have important consequences for hospitals' financial solvency, nurse staffing decisions, support for the safety net, and patient outcomes. And commercially insured populations may ultimately pay the bill for the increased utilization as hospitals attempt to raise their rates to commercial health plans in response to increased uncompensated care.
Relying on ED for primary care
The data also address the question of whether the increased ED use by the uninsured represents use of the ED for primary care that was previously provided in a traditional primary care setting, vs. care for more acute problems.
"After the Oregon Health Plan policy changes, the odds that an uninsured ED visit led to hospital admission increased by 50%," the researchers say. "Therefore, a disproportionate amount of the increase in ED use by uninsured patients than for other payer groups suggests that uninsured patients are forced to rely on EDs for primary care that insured patients are able to obtain in traditional primary care settings or that other factors such as nonfinancial barriers or patient preference lead uninsured patients to use EDs. At the same time, the observation that the proportion of ED visits requiring hospitalization was lower for uninsured patients than for other payer groups suggests that uninsured patients are forced to rely on EDs for primary care that insured patients are able to obtain in traditional primary care settings or that other factors such as nonfinancial barriers or patient preference lead uninsured patients to use EDs."
A disproportionate increase in drug- and alcohol-related ED visits and in other psychiatric visits among uninsured patients is consistent with other data about deteriorating access to outpatient care for these conditions. Although the study does not provide definitive evidence about the cause of the increase, the researchers say that Oregon Health Plan enrollees with behavioral health conditions may have stopped paying Oregon Health Plan premiums when services such as methadone maintenance and outpatient counseling were no longer covered, using EDs instead.
"As policy-makers contemplate fundamental changes to Medicaid nationwide, these events in Oregon should provide a warning about a potential large increase in emergency department use by the uninsured in the United States," Dr. Lowe said. "Cost-cutting measures may have substantial and lasting impacts on the health care system, and more importantly on its most vulnerable patients."
Access the report, Lowe RA, McConnell KJ, Vogt ME. Impact of Medicaid Cutbacks on Emergency Department Use: The Oregon Experience. Ann Emerg Med April 17, 2008, at: www.annemergmed.com/article/S0196-0644(08)00426-5/abstract.
Medicaid cuts in Oregon were followed by increases in both hospital emergency department (ED) use and hospitalization of the uninsured. A study published online April 17, 2008, in the Annals of Emergency Medicine says federal legislation facilitating similar Medicaid changes in other states may lead to higher ED use and hospitalizations elsewhere.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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