MACPAC Debunks Myths of ED Overuse by Medicaid Enrollees

The provision of care in emergency departments (ED) makes up only 4 percent of overall Medicaid spending, according to an issue brief by the Medicaid and CHIP Payment and Access Commission (MACPAC), though increased access to primary care could further lessen Medicaid’s ED spending The issue brief, which addresses commonly held beliefs about the use of the ED in Medicaid stemming from expansion under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), provides “a more balanced picture” of the program, “informed by the latest research.”

Background

Care is expensive in EDs, according to the report, because of their need for 24-hour staff and resource availability. Additionally, “the hospital settings in which most EDs are based have both high overhead and fixed costs.” Because Medicaid enrollees seek care in EDs more than privately insured and uninsured individuals, state Medicaid programs must closely monitor the use of EDs by their beneficiaries. Payers and health plans also play a role in keeping costs down by educating enrollees about the proper ED use and providing quick access to care in alternate settings.

ED Use by Medicaid Enrollees

Non-urgent ED visits by non-elderly Medicaid patients account for only 10 percent of ED visits, which is “a proportion comparable to that of privately insured patients,” according to the issue brief. Thus, most of the ED visits by these patients are for urgent symptoms and serious medical issues requiring immediate medical attention.

Evidence is conflicting on whether the use of the ED by adult Medicaid enrollees is increasing. However, the MACPAC did find that barriers to timely care have resulted in frequent use of the ED by Medicaid enrollees. The issue brief notes, “Despite the fact that nearly all Medicaid enrollees report having a usual place of care other than the ED, approximately one-third of adult and 13 percent of child enrollees have reported barriers to finding a doctor or delays in getting needed care.” These types of delays were more common among Medicaid enrollees than privately insured individuals and reduced with increased access to after-hours care.

There was insufficient evidence to show whether ED use would surge with Medicaid expansion throughout 2014.

Programs to Reduce ED Use

According to the issue brief, state Medicaid programs have utilized programs to reduce ED use, such as diverting patients with non-urgent complaints to lower-cost care settings (which has not proven to be a significant cost-saver) and charging copayments for non-urgent ED use. Alternative sites for non-emergency care, as well as extended hours and next-day appointments, are being more frequently offered to patients who would normally choose the ED. The increased availability of primary care could garner more efficient ED spending, but new delivery models are needed to address the needs of frequent ED users.