Abstract
Objective. To test interventions to decrease the utilization of hospital emergency departments (EDs) for routine, nonemergent health care among Medicaid recipients.
Methods. Families of a Medicaid-recipient child presenting to a children's hospital ED for nonurgent problems received information from either a health professional or a clerical employee about the importance of a primary care provider and assistance with making an appointment to the provider of their choice. The health professional continued to work with her assigned families in eliminating barriers to appropriate utilization of a primary care provider for up to 3 months after the index ED visit. A third (comparison) group received no intervention. Subsequent health care utilization for each enrollee was tracked via Ohio Medicaid claims data throughout the four subsequent 6-month periods after the index ED visit.
Results. Children in the intervention groups had 11.1% and 14.5% fewer nonurgent ED visits in the 6 months after the index ED visit with a concomitant decrease in cost for this type of care when compared with the comparison group during the same time period. No difference in the number of preventive or ill-child primary care visits was seen. There was no difference in health care cost or utilization in the time period 6 to 24 months after the intervention.
Conclusions. Interventions in pediatric EDs aimed at decreasing subsequent ED utilization for nonurgent care can be effective, resulting in modest decreases in the cost of health care for a Medicaid population.
- ED =
- emergency department •
- PCP =
- primary care provider •
- HMO =
- health maintenance organization •
- CPT =
- Current Procedural Terminology •
- ICD-9 =
- International Classification of Diseases, 9th Revision
In the United States, poor children may have less access to preventive health care than more affluent children,1 2and may be more likely to seek routine, nonurgent care through emergency departments (EDs) rather than through primary care providers (PCPs) such as general pediatricians or family physicians.3 4 Such patterns of care certainly interrupt continuity of care, may seriously affect the child's health,5 and, because ED fees are characteristically much higher than those in a primary care setting, contribute to the increase in society's cost for health care. Therefore, the potential exists to improve health care while decreasing costs by intervening to redirect low-income patients from EDs into primary care settings.
This study tested the effectiveness of an intervention designed to: 1) decrease the utilization of the ED as a source of nonurgent care; 2) increase the utilization of PCP for preventive and nonurgent care; and 3) decrease the overall cost of medical care for a population of Medicaid-recipient children.
METHODS
Medicaid-recipient children not currently enrolled in a managed-care program who sought care in the Children's Hospital Emergency Department, Columbus, Ohio, from January through August, 1991, for nonurgent problems were eligible for admission into the study. Many alternatives were available in the community for such care including evening and weekend office hours, after-hour telephone availability, free-standing urgent care centers, and other hospital EDs. Because all eligible children were in fee-for-service Medicaid, no gatekeeping barriers were set up to discourage nonurgent ED utilization. The nonurgent nature of their condition was determined by triage by a trained registered nurse on arrival in the ED as “stable, no noted distress; care could be delayed at least 4 to 6 hours and/or referred to a clinic for nonemergency treatment,” although no patient was turned away from the ED for care. Intervention workers were assigned to work at varying times and shifts in the ED to enroll patients. Patients were enrolled into the minimal intervention or case management group depending on which worker was on duty on that shift. Comparison group patients consisted of patients who did not meet an intervention worker because they presented at a time when no worker was on duty or at a time when the worker was busy speaking with other families.
Minimal intervention group families were enrolled by a clerical employee without specific health professional training. She carefully explained the value of preventive care and, in particular, the advantages of primary care for problems such as the concern bringing the family to the ED that day. If the family currently had a PCP with whom they were pleased, the worker emphasized the importance of continuity of care at that site. If the family did not currently have a PCP, the worker assisted the family in choosing a provider which seemed to meet their needs using the primary care referral book for reference. This referral book was developed through a mail and telephone survey of all pediatricians, family physicians, general practitioners, osteopathic physicians, and clinics in our county to determine the provider's willingness to receive referrals of Medicaid recipient children for primary care services. Additionally, information concerning hours/days of practice, the availability of public transportation and parking, the educational background of the physician(s), other services offered on site, and type of after-hours availability, if any, was collected. The worker used this referral book to assist the family in making the first appointment with the PCP and followed up to determine compliance. Workers for the minimal intervention group were involved with families only until the first primary care appointment was completed.
Enrollees into the case management intervention group were staffed by a case manager, either a pediatric nurse or pediatric social worker. An enrollment interview similar in content to that for the minimal intervention group was used except that more in-depth information concerning potential barriers to care was included by these health professionals. Again, the referral book was used to assist the family in identifying a PCP but in the case management group, the worker remained in contact with the family for up to 3 months. During this follow-up period, the worker provided case management and attempted to eliminate barriers that she or the family felt interfered with appropriate utilization of primary care services. The two case managers were assigned to varying days and shifts and approached families for enrollment as time allowed; therefore assignment to a nurse or social worker depended on which worker, if any, was available during the time the family presented for care. Families presenting to the ED during days/shifts not covered by an intervention worker and hence not receiving assistance in referral to a PCP formed the comparison group. To avoid inadvertent bias regarding day and/or time of ED presentation between intervention and comparison groups, workers were assigned to varying shifts and days of the week.
Outcome measures (dependent variables) for all three groups were based on claims paid data received directly from the Ohio Department of Human Services Medicaid Program billing computers and included all billings for services for enrollees during the 2 years after enrollment. These claims were grouped into four 6-month periods, that is, 0 to 6 months, 6 to 12 months, 12 to 18 months, and 18 to 24 months after the index ED visit.
Throughout the time period covered in this study, all welfare recipients had the option of voluntarily enrolling in one of two Medicaid health maintenance organizations (HMO)s. Changes from fee-for-service to managed care or vice versa could occur at the beginning of any month. Because claims data were not available for analysis during periods of HMO enrollment for any given child, or during periods when the child was not eligible for Medicaid coverage, days of fee-for-service eligibility were calculated for each child and compared among groups. All claims were classified into visit groups based on Current Procedural Terminology (CPT) codes (see Table1). The validity of our defined groupings of ED visits as urgent or nonurgent was determined by blinded independent review of medical records by two pediatricians for a random sample of 200 visits. Agreement was 97.6% between the two reviewers (κ-free coefficient6 = 0.951), 91.1% (κ-free coefficient = 0.823), and 91.8% (κ-free coefficient = 0.836), respectively, between the two reviewers and the CPT codes.
Identification of Visit Type by CPT and ICD-9 Codes
Primary care visits were classified as illness care visits and preventive visits based on CPT and International Classification of Diseases, 9th Revision (ICD-9) codes (Table 1). Total emergency visits includes urgent and nonurgent emergency care visits. All pharmaceutical claims were grouped together. Total health care expenditure included the above categories as well as all inpatient care, home care, ancillary services, and durable medical equipment.
The statistical analysis of the data included using the χ2 test, the Kruskal-Wallis, and the Mann-Whitney statistics, the latter two tests reflecting the nonnormal distribution of health care utilization data. The study was approved by the Children's Hospital Human Subjects Review Committee.
RESULTS
Only 5 families who were approached by the study personnel and offered enrollment in the program refused to participate. Of the remaining 709 who agreed to participate, 359 were ineligible because of enrollment in a voluntary Medicaid HMO at the time of the index ED visit and 35 were dropped from data analysis because of inability to match the child with claims data. Of 1207 Medicaid patients presenting to the ED with nonurgent problems when intervention workers were not available, 556 were eliminated because of HMO enrollment and 38 could not be matched with claims data. The remaining data sets included 135 for minimal intervention, 180 for case management, and 613 in the comparison groups. There were no significant differences among the three groups in either the number dropped because of HMO membership or claims data mismatch. Only 52% of the original study participants maintained Medicaid eligibility for the entire 24 month period, often because of failure to process recertification promptly or because of HMO enrollment. There was no difference in length of eligibility among the three study groups during either the initial 6-month follow-up period or the entire 24 month follow-up period (Table2).
Demographic Data (%)*
In addition to claims data, demographic information was available for most enrollees in all three study groups via the hospital information system and included child's age, race, sex, and type and location of neighborhood of residence as indicated by zip code (Table 2). There were no significant differences among the three groups for these variables.
The utilization of various types and the associated costs were analyzed for each successive 6-month period. The results for the first 6-month period after the index ED visit are summarized in Tables3 and 4. There were 11.1% and 14.5% fewer nonurgent ED visits among the two intervention groups as compared with the comparison group with the greater effect seen with the more intensive intervention (P < .01; Table 3). The expenditure for this category of care was also significantly decreased during this period with children from the minimal intervention group costing an average of $143 and case-managed children $140 per patient and as compared with $160 for those who received no intervention, a savings of 10.6% and 12.5% (P < .04; Table 4). Expenditures for this type of care accounted for 22.5% to 25.4% of the average total Medicaid health-care expenditure per child for this period. Not surprisingly, the number of nonurgent ED visits was more than 10 times the number of ED visits classified as truly urgent in nature among all three groups of patients. Emergency services were used considerably more often for illness care than primary care clinics or physicians among all three groups.
Health Care Utilization During First Six Months After Index ED Visit*
Health Care Expenditures During First Six Months After Index ED Visit*
There were no differences in number of truly urgent ED visits, preventive primary care, ill primary care visits, or in their costs during this first 6-month period. The total Medicaid expenditures for care per enrolled child were not significantly different among groups. Utilization of pharmacy services was quite high with at least one filled prescription in the first 6-month study period and in each successive period among the entire population for the duration of the study.
No differences were seen in the utilization patterns or costs among the groups during the last three 6-month periods.
The full-time clerical worker in the minimal intervention was able to work with approximately 60 patients per week at an average cost of $6.13 per patient. Case managers were able to enroll approximately 20 patients per week while continuing follow-up with existing enrollees. Including the cost of this prolonged follow-up, the intervention cost per patient was $30.99 for the nurse and $30.43 for the social worker. These costs reflect neither the cost of data collection for purposes of the research study nor the administrative costs of program start-up.
DISCUSSION
Thirty years ago, Alpert and colleagues7demonstrated the lower rates of hospitalization, surgery, and ill care visits and increased number of health maintenance visits for children enrolled in a comprehensive primary care program. The same group8 also pointed to the increased costs encountered when primary medical care is delivered in hospital EDs, whereas Rochester researchers demonstrated reductions of ED visits, especially for children, when enrolled in a comprehensive neighborhood health center.9 10 Still the utilization of emergency services, particularly by low-income populations, continues to be a significant problem,11-14 and contributes to the increase in national health care costs.15
Previous attempts to refer nonurgent ED patients have had variable success. Straus and colleagues16 referred children presenting to their hospital ED with nonurgent problems to a regular PCP with 34% success, but no reduction in ED usage occurred after enrollment. A rather extensive educational program for HMO-enrolled families of asthmatic children likewise failed to decrease subsequent ED utilization.17
Hansagi and colleagues18 in Sweden conducted a study of ED patients with nonurgent complaints. A specially trained nurse advised and referred the study group to PCPs for care instead of receiving care by ED staff. If patients so wished, however, they then were seen by the hospital ED physicians. The comparison group did not interact with the nurse-adviser. One year after the intervention hospital records were reviewed to determine hospital clinic and ED utilization by both groups in the subsequent time period. The study group decreased subsequent utilization of the ED although utilization increased among comparison children. Interestingly, however, among those classified as frequent ED users in both study and comparison groups, no decreased utilization was seen.
Such previous studies of interventions designed to decrease ED utilization in other than managed-care environments have relied on subsequent ED utilization at the same ED and do not report on subsequent utilization of emergency services at other hospitals. Changes in cost of care are not documented and nonurgent ED utilization is not differentiated from ED utilization for the true emergencies that the ED is intended to treat. By using Medicaid claims data, virtually all health care utilization by the enrollee which occurred during periods of Medicaid enrollment is represented in our data. Our utilization of billing codes to determine the degree of emergency involved in the visit distinguished urgent from less appropriate ED utilization.
Delaware initiated their statewide Voluntary Initiative Program in 1993 to attempt to increase access to primary care by referral of Medicaid clients to a regular source of care. During the year after referral, ED utilization by program participants decreased 24% and physician outpatient visits increased 50% compared with decreases of 4% in ED utilization and 13% in physician visits for nonparticipants during the same time period.19 It should be noted, however, that participants for this program were self-referred and it is likely that they were highly motivated to more appropriately used the health care system available to them.
Numerous studies have reported the utilization of gatekeeping strategies in Medicaid managed-care programs to deal with the expensive problem of excessive nonurgent ED utilization. These have had mixed results,20-22 and carry with them the risks involved with forcibly limiting patient-initiated access to care as opposed to reliance on reeducation of clients to seek health care services appropriate to their actual need.
Our study of an ED-based educational intervention to alter fee-for-service Medicaid-recipients' utilization of the ED for nonurgent care successfully demonstrated a short-term decrease in nonurgent ED visits and their attendant costs during a 6-month period after the index visit. The interventions we used should be easily replicated elsewhere. Medicaid savings per case-managed child was $20 but the cost of the intervention was estimated to be approximately $30. On the other hand, only $6.13 was expended on the minimal intervention for a net savings of $17 per patient. Unfortunately, in follow-up throughout a 2 year period, it was clear that the effect of our intervention was short-lived and we were unable to document a concomitant increase in primary care utilization. Further study, possibly involving reinforcement of the intervention during the first 1 to 2 years after referral to primary care, is needed to identify strategies to encourage more appropriate and effective utilization of the health care system by this population.
ACKNOWLEDGMENTS
This study was supported by a grant from the Ohio Department of Human Services, contract #C91–097–0.
The authors wish to acknowledge the skilled and tireless assistance of Carol Stumpf; Terri Richards, RN; Jody Bush, MSW, LISW; Robin Hite; Julie Robbins, MS; and Laura Sova, MS, in the successful completion of this project. Thanks also are extended to John Hayes, PhD, for statistical assistance.
Footnotes
- Received October 13, 1997.
- Accepted December 16, 1997.
Reprint requests to (L.K.G.) Children's Hospital, 700 Children's Dr, Columbus, OH 43205.
REFERENCES
- Copyright © 1998 American Academy of Pediatrics