Tag: emergency department use

Video: Emergency Department Use in California

Hospital emergency departments (EDs) are an important part of California’s health care system. They are sometimes called the safety net of the safety net because they provide care to all comers. Policymakers, health plans, and health providers have long focused on ED use, partly because it serves as a proxy for lack of access to other, less costly forms of health care. So how has the expansion of insurance coverage under the Affordable Care Act (ACA) affected ED use in California? At an event last week in Sacramento, PPIC researcher Shannon McConville outlined a new PPIC report that addresses this question, and a panel of experts offered their perspectives on recent ED trends.

While many predicted that coverage expansion would reduce ED use by providing access to other kinds of medical care, such as primary care physicians, some worried that because insurance coverage typically reduces patients’ out-of-pocket costs, the ACA would increase ED use. The good news is that the PPIC report estimates that ED use rates would be higher in the absence of the ACA. But ED use statewide has been increasing for the past decade. To get a sense of how recent trends in ED use are being experienced and addressed around the state, PPIC convened a panel of experts.

All of the panelists highlighted the importance of finding out why people are using EDs. Some frequent ED users may not know about other ways to get medical care, while others may have behavioral or mental health issues that could be addressed more effectively by other kinds of care—from housing assistance to substance abuse programs. As Sara Kate Levin, medical director for Contra Costa Health Services, put it, “What are the unmet social needs that are driving a lot of this high utilization?”

But filling information gaps and addressing behavioral and mental health issues does not solve all ED use problems. In many areas, there is a scarcity of primary care doctors and urgent care clinics, and many patients cannot take time off to go to medical appointments during the workday. Moreover, primary care doctors sometimes refer their privately insured patients to EDs, in part so they won’t have to wait for tests.

This range of issues points to what Renee Hsia, an ED physician at Zuckerberg San Francisco General Hospital and a professor of emergency medicine and health policy, called “the elephant in the room”: because the United States has “a very market-based approach to health care,” there are two very different stories about ED use. On the one hand, EDs in affluent areas broadcast their availability and convenience. On the other hand, there are long waits for treatment at EDs serving low-income areas. “In some areas, your ER is a revenue center . . . and in some places, where you don’t have paying patients, your ER is a cost center.”

Jennifer Rasmussen, vice president of health care services at Molina Healthcare of California, highlighted the geographical differences across the state that make it difficult to find “one size fits all” solutions. She pointed out that Molina serves Imperial and San Bernardino Counties, “a vast geography” with fewer social services than a dense urban area has to offer. In other words, “a solution for Imperial County is not going to be the same as a solution for San Francisco.”

Emergency Departments and the Affordable Care Act

Coverage expansions under the Affordable Care Act (ACA) have resulted in a dramatic decline in the uninsured population in California. Much of the coverage gains have been driven by expanded eligibility for Medi-Cal, the state’s Medicaid program, which has seen a nearly 60% increase in enrollment since January 2014. With this large Medi-Cal expansion comes concerns about controlling costs, ensuring adequate access to care, and supporting the state’s health care safety net.

Monitoring how often people seek care in California’s emergency departments offers important insights—in part because frequent use can signal poor access to other medical care options. Hospitals in some parts of the state have reported growing demand for emergency care services in recent years. In a new study published this month in the journal Health Affairs, we examined emergency department use to understand how things have changed since the implementation of the ACA.

After controlling for factors such as patient age and health status, we found the odds of being a frequent emergency department user—with four or more annual emergency department visits—were significantly lower for Medi-Cal patients after the ACA. The odds of frequent use among the uninsured declined even more, while those with private insurance experienced little change. At the same time, however, there has been an overall increase in both the share and the absolute number of emergency department patients who are frequent users—despite the lower odds of frequent emergency department use after the ACA. We found that frequent users accounted for 7.9% of emergency department patients in the two years before the ACA, compared to 8.5% in the two years after.

Both before and after the ACA, the largest predictors of frequent emergency department use were having a diagnosed mental health condition or substance use disorder. This finding suggests state efforts to better integrate physical and behavioral health services for Medi-Cal enrollees could help lower frequent emergency department visits. Given that Medi-Cal is now the primary coverage source for more than two-thirds of frequent emergency department users, care plans managed by Medi-Cal will be a key player in efforts to manage emergency care moving forward.

In future work, we will be studying in more depth how changes in insurance coverage affected emergency department use across the state—with a particular focus on regions that saw the largest declines in their uninsured rates.