Emergency department care coordination strategies and perceived impact under Maryland's hospital payment reforms

Galarraga, Jessica E.; DeLia, Derek; Wilhite, Daniel; Romero-Barrientos, Ronald; O'Sullivan, Kaitlin; Noccolino, Donna; Pimentel, Laura; Woodcock, Cynthia; Fairbanks, Rollin J.; Pines, Jesse M.

doi:10.1016/j.ajem.2020.12.048

Cited by 3 publications

(6 citation statements)

References 23 publications

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“…One example is the global budgets used in Maryland hospitals, which reduced hospitals' susceptibility to the large volume shifts in the COVID-19 pandemic. 25,26 A capitation-based model for ED clinician services could be worth exploring, with payment based on the population expected to be served. This could be either a full model for ED clinician revenue or a "floor" on revenue to cushion against financial shocks.…”

Section: Discussionmentioning

confidence: 99%

The Effect of the COVID-19 Pandemic on the Economics of United States Emergency Care

Pines

Zocchi

Black

et al. 2021

Annals of Emergency Medicine

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Study objective: We describe how the coronavirus disease 2019 (COVID-19) pandemic affected the economics of emergency department care (ED). Methods:We conducted an observational study of 136 EDs from January 2019 to September 2020, using 2020-to-2019 3-week moving ratios for ED visits, complexity, revenue, and staffing expenses. We tabulated 2020-to-2019 staffing ratios and calculated hour and full-time-equivalent changes.Results: Following the COVID-19 pandemic's onset, geriatric (age !65), adult (age 18 to 64), and pediatric (age <18) ED visits declined by 43%, 40%, and 73%, respectively, compared to 2019 visits and rose thereafter but remained below 2019 levels through September. Relative value units per visit rose by 8%, 9%, and 18%, respectively, compared to 2019, while ED admission rates rose by 32%. Both fell subsequently but remained above 2019 levels through September. Revenues dropped sharply early in the pandemic and rose gradually but remained below 2019 levels. In medium and large EDs, staffing and expenses were lowered with a lag, largely compensating for lower revenue at these sites, and barely at freestanding EDs. Staffing and expense reductions could not match revenue losses in smaller EDs. During the pandemic, emergency physician and advanced practice provider clinical hours and compensation fell 15% and 27%, respectively, corresponding to 174 lost physician and 193 lost advanced practice provider full-time-equivalent positions. Conclusion:The COVID-19 pandemic adversely impacted the economics of ED care, with large drops in overall and, in particular, low-acuity ED visits, necessitating reductions in clinical hours. Staffing cutbacks could not match reduced revenue at small EDs with minimum emergency physician coverage requirements. [

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Section: Discussionmentioning

confidence: 99%

The Effect of the COVID-19 Pandemic on the Economics of United States Emergency Care

Pines

Zocchi

Black

et al. 2021

Annals of Emergency Medicine

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“…It is well known that those with multiple chronic conditions are one of the target populations for effective care coordination and individualized care plans [12]. While some EDs in the state of Maryland have effectively managed care-coordination by hiring dedicated staff, others need to invest more in care coordination [27].…”

Section: Resultsmentioning

confidence: 99%

“Frequent and Recurrent Emergency Department Visits: A State Level Analysis for Maryland, 2017-2019”

Kelekar

Abdesslem

Tran

et al. 2022

Preprint

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Background Frequent or repeat ED visits make up over 20% of the total ED visits, while frequent users constitute up to 8% of all ED users. While some studies have analyzed ED encounters over a single healthcare system, a single year or a condition, this study examines frequent and recurrent ED utilization for the state of Maryland over three years. Methods Using 2017–2019 State Emergency Department Databases (SEDD), we conducted bivariate and multivariate analyses and identified patient/community level characteristics associated with frequent (> 4 visits/year) and recurrent frequent ED users (two and three consecutive years) in Maryland. Results Of the total 5,331,843 ED visits, frequent visits were 24.4% (1,301,301) while frequent users made up 7.16% (234,973) of all ED users. Females [OR = 1.30, 95% CI 1.24, 1.36] and patients aged 21–44 [OR = 2.41, 95% CI 2.24,2.60] were more likely to visit the ED recurrently than males, children and adolescents respectively. Compared to those with private insurance and no chronic conditions, Medicaid beneficiaries were 2.41 (95% CI 2.24,2.60) and those with multiple chronic conditions was 2.34 [95% CI 2.14,2.54] times more likely to be recurrent frequent ED users respectively. The NH Blacks were 26% [95% CI 1.25,1.28] more likely to be frequent users than NH White patients while those from the lowest income quartile were 69% [95% CI 1.66,1.71] and 33% [95% CI 1.21,1.46] more likely to be frequent and recurrent frequent ED users compared to the highest income quartile. Compared to residents of large metropolitan areas, patients from micropolitan areas were 43% [95% CI 1.38,1.48] while those living further from an ED were 9% [95% CI 1.09, 1.10] were more likely to be frequent ED users. Conclusions Frequent and recurrent frequent ED users in the state of Maryland were associated with being female, 21–44 years old, NH Black, Medicaid beneficiaries, with multiple chronic conditions and reside in a lower income zip code. Frequent ED users were also more likely to reside micropolitan areas, and further from an ED facility. We propose recommendations to stakeholders to invest in care coordination and IT infrastructure, and expand community access to outpatient care.

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“…Since ED returns are associated with difficulty in accessing timely follow‐up care and patient fears or uncertainty of disease progression, there may have been improvements in health system navigation and support for patient self‐management, either by way of care coordination or by community health resources, for the uninsured and Medicaid insured after GBR implementation 43 . Investments in ED care coordination to reduce avoidable utilization and improve access to outpatient resources across MD with the implementation of GBR have been reported, which may explain the observed improvements in ED return payer gap disparities 12 . Although payer gap disparities for the most part remained stable with the admission rates among returns, there was a notable widening of the disparity gap for the Medicaid insured.…”

Section: Discussionmentioning

confidence: 99%

“…The decline in ED returns not only reflects potential improvements in quality and/or care transitions but also may yield cost savings for the health system 44 . Further research is needed to identify the ED‐specific care delivery strategies, such as care coordination approaches, that are driving the improvements in ED returns under Maryland's global budget revenue reform model 12 …”

Section: Discussionmentioning

confidence: 99%

“…However, observed reductions in admissions may potentially have an unintended consequence of increasing ED returns as well as hospitalizations or mortality among returns if patients should have been admitted during the initial encounter. On the other hand, one of the intended effects of GBR is that hospitals invest in care coordination and address social determinants, which may reduce the risk of returns and increase access to other sources of care 11,12 …”

Section: Introductionmentioning

confidence: 99%

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Effects of Maryland’s global budget revenue model on emergency department utilization and revisits

Galarraga

DeLia

Huang

et al. 2021

Academic Emergency Medicine

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Background In 2014, Maryland (MD) implemented a “global budget revenue” (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR’s effects on emergency department (ED) visits, admissions, and returns. Methods We performed an interrupted time‐series analysis with difference‐in‐differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR’s effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72 h and 9 days. We also examined rates of admission, intensive care unit (ICU) stay, and in‐hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. Results ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post‐GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in‐hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non‐Hispanic Whites and non‐Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. Conclusions GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.

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Emergency department care coordination strategies and perceived impact under Maryland's hospital payment reforms

Cited by 3 publications

References 23 publications

The Effect of the COVID-19 Pandemic on the Economics of United States Emergency Care

The Effect of the COVID-19 Pandemic on the Economics of United States Emergency Care

“Frequent and Recurrent Emergency Department Visits: A State Level Analysis for Maryland, 2017-2019”

Effects of Maryland’s global budget revenue model on emergency department utilization and revisits

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