Most Medicaid Emergency Department Visits Involve Urgent or Serious Symptoms

Most Medicaid Emergency Department Visits Involve Urgent or Serious Symptoms

Research Challenges the Assumption that Medicaid Recipients Frequently Visit Emergency Departments for Non-Urgent Care

News Release
July 11, 2012

FOR MORE INFORMATION, CONTACT:
Alwyn Cassil (202) 264-3484 or [email protected]

WASHINGTON, DC -- Despite the widespread belief that Medicaid enrollees routinely seek care in hospital emergency departments for minor health issues, a national analysis published by the Center for Studying Health System Change (HSC) reveals that the vast majority of ED visits by nonelderly Medicaid beneficiaries are prompted by symptoms indicating urgent or more severe medical conditions.

Two categories of data from emergency department encounters are generally relied upon to characterize ED utilization -- the patient's presenting symptoms as evaluated by triage personnel to establish how quickly attention is needed, and the eventual diagnoses rendered after a physician's examination.

Roughly 10 percent of ED visits by nonelderly Medicaid patients were classified as nonurgent based on their symptoms, versus approximately 7 percent for nonelderly individuals with private insurance in 2008, according to this Robert Wood Johnson Foundation (RWJF)-funded analysis. By contrast, slightly over half of both Medicaid and privately insured visits fell into the emergent category -- requiring immediate care -- or the urgent category -- needing evaluation within one hour. The analysis drew on the most recently available data from the National Hospital Ambulatory Medical Care Survey administered by the Centers for Disease Control and Prevention.

It is true that nonelderly Medicaid recipients utilize emergency departments at higher rates than their privately insured counterparts. In 2008, individuals aged 0 to 64 enrolled in Medicaid had 45.8 ED visits per 100 enrollees, compared with 24.0 visits per 100 nonelderly people covered by private insurance.

"The bulk of the gap in ED usage between nonelderly Medicaid and privately insured individuals stems from greater utilization by Medicaid patients for urgent and semi-urgent symptoms requiring timely medical intervention," explained HSC Senior Researcher Emily Carrier, M.D., M.C.S.I., a practicing emergency physician and lead author of the study. Her co-authors included Anna S. Sommers, Ph.D., a former HSC senior researcher, and Ellyn R. Boukus, M.A., an HSC health research analyst.

Nonelderly Medicaid enrollees visited EDs for emergent conditions -- those demanding immediate attention -- at a rate of 5.6 visits per 100, compared to 3.6 per 100 among the privately insured. For urgent visits -- where evaluation was needed within an hour -- Medicaid patients had 18.1 visits per 100 enrollees versus 9.6 per 100 for those with private coverage. For semi-urgent visits -- requiring evaluation within one to two hours -- the Medicaid rate stood at 10.4 per 100 nonelderly enrollees, while the privately insured rate was 5.5 per 100.

Detailed results appear in a new HSC Research Brief titled Dispelling Myths About Emergency Department Use: Majority of Medicaid Visits Are for Urgent or More Serious Symptoms.

The researchers pinpointed two diagnosis categories with the greatest potential for lowering ED utilization among both nonelderly Medicaid and privately insured populations, assuming access to suitable alternative care settings existed: first, acute respiratory infections and other common childhood infections, and second, injuries across all nonelderly age groups.

As an illustration, diagnoses involving acute respiratory and other common childhood infections along with injuries together represent roughly 53 percent of ED visits by Medicaid-enrolled children aged 0 to 12 and nearly 60 percent of ED visits by privately insured children in the same age range. Although some infections and injuries will be too serious for treatment elsewhere, lower-cost facilities capable of delivering a moderate level of care with prompt response times could likely decrease emergency department usage.

"Diagnostic data support the notion that patients presenting to the ED with certain conditions could receive treatment in less costly settings, yet standard primary care offices may not be a viable alternative in every case. Many primary care practices cannot accommodate patients rapidly enough to handle urgent issues and may lack the specialized equipment needed on-site. Alternative care venues would need to offer rapid attention for urgent cases and be equipped with the appropriate services and tools to diagnose and manage less serious conditions," the study concludes.

The Center for Studying Health System Change was a nonpartisan policy research organization dedicated to delivering objective and timely research on the evolving U.S. health system to support policy makers and improve health care policy. HSC, headquartered in Washington, D.C., was affiliated with Mathematica Policy Research.

Sources and Further Reading

Centers for Disease Control and Prevention — National Hospital Ambulatory Medical Care Survey — The CDC survey that provided the emergency department utilization data analyzed in this study.

Centers for Medicare & Medicaid Services — Medicaid Program Overview — CMS information on Medicaid eligibility, enrollment, and benefits relevant to the covered population examined in this research.

Kaiser Family Foundation — Medicaid and Emergency Department Use — KFF analysis of emergency department utilization patterns among Medicaid enrollees and the policy implications.

Health Affairs — Emergency Department Utilization Research — Peer-reviewed research on ED visit patterns, triage acuity, and the role of primary care access in reducing emergency department use.

Robert Wood Johnson Foundation — Dispelling Myths About ED Use — RWJF-funded HSC research challenging assumptions about non-urgent Medicaid emergency department visits.