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The objective of this study was to determine the patient characteristics and health care utilization patterns that predict frequent emergency department (ED) use (≥4 visits per year) over time to assist health care organizations in targeting patients for care management. This was a retrospective, population-based study of 13,265 Medicaid children aged 0-20 years who were attributed to a single pediatric accountable care organization for at least 2 consecutive years between June 2012 and May 2015. Year-to-year persistence as a frequent ED user was 36.3% (95% confidence interval [CI]: 33.4 to 38.4), which does not support the notion that once a frequent user, always a frequent user. Hence, interventions to reduce frequent ED use may appear to be effective when ED use would have regressed toward the mean without any intervention. At an individual patient level, predictability of frequent ED use was 0.437 (95% CI: 0.358 to 0.485) across frequent ED users of all ages compared with 0.723 (95% CI: 0.435 to 0.824) for those aged <1 year. Accordingly, this latter group may be a better target for interventions than frequent ED users generally.

Importance: Little is known about the effect of pediatric accountable care organizations (ACOs) on the use and costs of health care resources, especially in a Medicaid population., Objective: To assess the association between the length of consistent primary care (length of attribution) as part of an ACO and the use and cost of health care resources in a pediatric Medicaid population., Design, Setting, and Participants: A retrospective study of Medicaid claims data for 28,794 unique pediatric patients covering 346,277 patient-attributed months within a single children's hospital. Data were collected for patients attributed from September 1, 2013, to May 31, 2015. The effect of the length of attribution within a single hospital system's ACO on the use and costs of health care resources were estimated using zero-inflated Poisson distribution regression models adjusted for patient characteristics, including chronic conditions and a measure of predicted patient use of resources., Exposures: Receiving a plurality of primary care at an ACO clinic during the preceding 12 months (attribution to the ACO)., Main Outcomes and Measures: The primary outcome measure was the length of attribution at an ACO clinic compared with subsequent inpatient hospitalization and subsequent use and cost of outpatient and ancillary health care resources., Results: Among the 28,794 pediatric patients receiving treatment covering 346,277 patient-attributed months during the study period, continuous attribution to the ACO for more than 2 years was associated with a decrease (95% CI) of 40.6% (19.4%-61.8%) in inpatient days but an increase (95% CI) of 23.3% (2.04%-26.3%) in office visits, 5.8% (1.4%-10.2%) in emergency department visits, and 15.3% (12.5%-18.0%) in the use of pharmaceuticals. These changes in the use of health care resources combined resulted in a cost reduction of 15.7% (95% CI, 6.6%-24.8%). At the population level, the impact of consistent primary care was muted by the many patients in the ACO having shorter durations of participation., Conclusions and Relevance: These findings suggest significant and durable reductions of inpatient use and cost of health care resources associated with longer attribution to the ACO, with attribution as a proxy for exposure to the ACO's consistent primary care. Consistent primary care among the pediatric Medicaid population is challenging, but these findings suggest substantial benefits if consistency can be improved.

A consistent pattern in the nursing home industry is that non-profit institutions serve a lower proportion of Medicaid patients than do for-profit facilities. This is contrary to the expectation that non-profit, altruistically motivated firms should serve a larger proportion of the less profitable Medicaid patients than proprietary firms. The literature confirms this pattern empirically, but provides no theoretical basis for it, which is the contribution of this paper. Specifically, we show theoretically that information disparities between providers and consumers regarding quality fosters an environment in which the percentage of uninformed consumers is a key factor in determining public-private patient mix.