Copayments Did Not Reduce Medicaid Enrollees’ Nonemergency Use Of Emergency Departments

Mortensen, Karoline

doi:10.1377/hlthaff.2009.0906

Cited by 43 publications

(41 citation statements)

References 20 publications

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“…39–47 The remaining study found a significant relative increase of 34% in ED visits. 48 All studies took place in the United States. The intervention in seven studies was the requirement for patient copayment or coinsurance, and in three it was the implementation of a high deductible.…”

Section: Resultsmentioning

confidence: 99%

Non–Emergency Department Interventions to Reduce ED Utilization: A Systematic Review

Morgan

Chang

Alqatari

et al. 2013

Academic Emergency Medicine

139

117

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Objectives Recent health policy changes have focused efforts on reducing emergency department (ED) visits as a way to reduce costs and improve quality of care. This was a systematic review of interventions based outside the ED aimed at reducing ED use. Methods This study was designed as a systematic review. We reviewed the literature on interventions in five categories: patient education, creation of additional non-ED capacity, managed care, prehospital diversion, and patient financial incentives. Studies written in English, with interventions administered outside of the ED, and a comparison group where ED use was an outcome, were included. Two independent reviewers screened search results using MEDLINE, Cochrane, OAIster, or Scopus. The following data were abstracted from included studies: type of intervention, study design, population, details of intervention, effect on ED use, effect on non-ED health care use, and other health and financial outcomes. Quality of individual articles was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. Results Of 39 included studies, 34 were observational and five were randomized controlled trials. Two of five studies on patient education found reductions in ED use ranging from 21% to 80%. Out of 10 studies of additional non-ED capacity, four showed decreases of 9% to 54%, and one a 21% increase. Both studies on prehospital diversion found reductions of 3% to 7%. Of 12 studies on managed care, 10 had decreases ranging from 1% to 46%. Nine out of 10 studies on patient financial incentives found decreases of 3% to 50%, and one a 34% increase. Nineteen studies reported effect on non-ED use with mixed results. Seventeen studies included data on health outcomes, but 13 of these only included data on hospitalizations rather than morbidity and mortality. Seven studies included data on cost outcomes. According to the GRADE guidelines, all studies had at least some risk of bias, with four moderate quality, one low quality, and 34 very low quality studies. Conclusions Many studies have explored interventions based outside the ED to reduce ED use in various populations, with mixed evidence. Approximately two-thirds identified here showed reductions in ED use. The interventions with the greatest number of studies showing reductions in ED use include patient financial incentives and managed care, while the greatest magnitude of reductions were found in patient education. These findings have implications for insurers and policymakers seeking to reduce ED use.

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Section: Resultsmentioning

confidence: 99%

Non–Emergency Department Interventions to Reduce ED Utilization: A Systematic Review

Morgan

Chang

Alqatari

et al. 2013

Academic Emergency Medicine

139

117

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“…10,34,35 The first difference is a pre-post comparison of hospitals that implement TPR during the study period. The second difference is the experience of rural hospitals that did not participate in the program over the same time period.…”

Section: Methodsmentioning

confidence: 99%

Innovative payment mechanisms in Maryland Hospitals: An empirical analysis of readmissions under total patient revenue

Mortensen

Perman²,

Chen

2014

Healthcare

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Background The state of Maryland implemented innovative budgeting of outpatient and inpatient services in eight rural hospitals under the Total Patient Revenue (TPR) system in July, 2010. Methods This paper uses data on Maryland discharges from the 2009-2011 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Individual inpatient discharges from eight treatment hospitals and three rural control hospitals (n=374,353) are analyzed. To get robust estimates and control for trends in the state, we also compare treatment hospitals to all hospitals in Maryland that report readmissions (n=1,997,164). Linear probability models using the difference-in-differences approach with hospital fixed effects are estimated to determine the effect of the innovative payment mechanisms on hospital readmissions, controlling for patient demographics and characteristics. Results Difference-in-differences estimates show that after implementation of TPR in the treatment hospitals, there were no statistically significant changes in the predicted probability of readmissions. Conclusions Early evidence from the TPR program shows that readmissions were not affected in the 18 months after implementation. Implications : As the health care system innovates, it is important to evaluate the success of these innovations. One of the goals of TPR was to lower readmission rates, however these rates did not show consistent downward trends after implementation. Our results suggest that payment innovations that provide financial incentives to ensure patients receive care in the most appropriate setting while maintaining quality of care may not have immediate effects on commonly used measures of hospital quality, particularly for rural hospitals that may lack coordinated care delivery infrastructure.

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“…48 Three studies were of copayments implemented by state Medicaid programs. [49][50][51] Three of the 5 studies-1 within Kaiser and 2 studies of copayments implemented within the Oregon state Medicaid program-reported significant reductions in ED visits. The Kaiser study found that ED visit rates decreased with increasing copayment levels (adjusted relative rate $1 to $5: 0.962 [95% CI 0.955-0.970] up to $50 to $100: 0.765 [95% CI 0.756-0.774]).…”

mentioning

confidence: 99%

The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review

Raven

Kushel

et al. 2016

Annals of Emergency Medicine

110

115

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Twitter: @mravenEM.Study objective: Previous reviews of emergency department (ED) visit reduction programs have not required that studies meet a minimum quality level and have therefore included low-quality studies in forming conclusions about the benefits of these programs. We conduct a systematic review of ED visit reduction programs after judging the quality of the research. We aim to determine whether these programs are effective in reducing ED visits and whether they result in adverse events. Methods:We identified studies of ED visit reduction programs conducted in the United States and targeted toward adult patients from January 1, 2003, to December 31, 2014. We evaluated study quality according to the Grading of Recommendations Assessment, Development, and Evaluation criteria and included moderate-to high-quality studies in our review. We categorized interventions according to whether they targeted high-risk or low-acuity populations. Results:We evaluated the quality of 38 studies and found 13 to be of moderate or high quality. Within these 13 studies, only case management consistently reduced ED use. Studies of ED copayments had mixed results. We did not find evidence for any increase in adverse events (hospitalization rates or mortality) from the interventions in either high-risk or low-acuity populations.Conclusion: High-quality, peer-reviewed evidence about ED visit reduction programs is limited. For most program types, we were unable to draw definitive conclusions about effectiveness. Future ED visit reduction programs should be regarded as demonstrations in need of rigorous evaluation.

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Copayments Did Not Reduce Medicaid Enrollees’ Nonemergency Use Of Emergency Departments

Cited by 43 publications

References 20 publications

Non–Emergency Department Interventions to Reduce ED Utilization: A Systematic Review

Non–Emergency Department Interventions to Reduce ED Utilization: A Systematic Review

Innovative payment mechanisms in Maryland Hospitals: An empirical analysis of readmissions under total patient revenue

The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review

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