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Background: Although past research demonstrated that Medicaid expansions were associated with increased emergency department (ED) and primary care (PC) utilization, little is known about how long this increased utilization persists or whether postcoverage utilization is affected by prior insurance status., Objectives: (1) To assess changes in ED, PC, mental and behavioral health care, and specialist care visit rates among individuals gaining Medicaid over 24 months postinsurance gain; and (2) to evaluate the association of previous insurance with utilization., Methods: Using claims data, we conducted a retrospective cohort analysis of adults insured for 24 months following Oregon's 2008 Medicaid expansion. Utilization rates among 1124 new and 1587 returning enrollees were compared with those among 5126 enrollees with continuous Medicaid coverage (≥1 y preexpansion). Visit rates were adjusted for propensity score classes and geographic region., Results: PC visit rates in both newly and returning insured individuals significantly exceeded those in the continuously insured in months 4 through 12, but were not significantly elevated in the second year. In contrast, ED utilization rates were significantly higher in returning insured compared with newly or continuously insured individuals and remained elevated over time. New visits to PC and specialist care were higher among those who gained Medicaid compared with the continuously insured throughout the study period., Conclusions: Predicting the effect of insurance expansion on health care utilization should account for the prior coverage history of new enrollees. In addition, utilization of outpatient services changes with time after insurance, so expansion evaluations should allow for rate stabilization., Competing Interests: The authors have no conflicts of interest to report.

Study Objective: We compare the association between barriers to timely primary care and emergency department (ED) utilization among adults with Medicaid versus private insurance., Methods: We analyzed 230,258 adult participants of the 1999 to 2009 National Health Interview Survey. We evaluated the association between 5 specific barriers to timely primary care (unable to get through on telephone, unable to obtain appointment soon enough, long wait in the physician's office, limited clinic hours, lack of transportation) and ED utilization (≥1 ED visit during the past year) for Medicaid and private insurance beneficiaries. Multivariable logistic regression models adjusted for demographics, socioeconomic status, health conditions, outpatient care utilization, and survey year., Results: Overall, 16.3% of Medicaid and 8.9% of private insurance beneficiaries had greater than or equal to 1 barrier to timely primary care. Compared with individuals with private insurance, Medicaid beneficiaries had higher ED utilization overall (39.6% versus 17.7%), particularly among those with barriers (51.3% versus 24.6% for 1 barrier and 61.2% versus 28.9% for ≥2 barriers). After adjusting for covariates, Medicaid beneficiaries were more likely to have barriers (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 1.30 to 1.52) and higher ED utilization (adjusted OR 1.48; 95% CI 1.41 to 1.56). ED utilization was even higher among Medicaid beneficiaries with 1 barrier (adjusted OR 1.66; 95% CI 1.44 to 1.92) or greater than or equal to 2 barriers (adjusted OR 2.01; 95% CI 1.72 to 2.35) compared with that for individuals with private insurance and barriers., Conclusion: Compared with individuals with private insurance, Medicaid beneficiaries were affected by more barriers to timely primary care and had higher associated ED utilization. Expansion of Medicaid eligibility alone may not be sufficient to improve health care access., (Copyright © 2012. Published by Mosby, Inc.)

Objectives: During a series of reforms to the Tennessee Medicaid expansion program (TennCare) in 2005, approximately 171,000 adults were disenrolled from Medicaid. The objective of this study was to examine the statewide effect of such a disenrollment on Tennessee emergency department (ED) utilization., Methods: Administrative data on all ED visits in Tennessee from 2004 through 2006 were obtained from the State Emergency Department Database and State Inpatient Database under the Healthcare Utilization Project. Population statistics and uninsured estimates were obtained from the U.S. Census Bureau, and TennCare enrollment data were obtained from the State of Tennessee Department of TennCare. The proportion and rate of ED visits, assessed separately by payer type, were compared across a predisenrollment period from January 1, 2004, through July 31, 2005, and across a postdisenrollment period from August 1, 2005, through December 31, 2006. The proportion and rate of ED visits resulting in hospital admission, again assessed separately by payer type, were compared across the same disenrollment periods in a similar way. We fitted a series of linear models for the total number of ED visits and each proportion and rate, with various degrees of adjustment for seasonality and time trend., Results: The mean number of ED visits was 45,662 per week during the predisenrollment period and 44,463 per week during the postdisenrollment period (mean difference = -1,199; 95% confidence interval [CI] -1,722 to -676). By payer category, there was a decrease of 3,119 visits per week by TennCare beneficiaries and an increase of 2,203 per week by the uninsured. After disenrollment, the absolute proportion of ED visits by TennCare beneficiaries significantly decreased by 6.2% (95% CI = -6.6% to -5.8%), and the absolute proportion of uninsured ED visits increased by 5.3% (95% CI = 4.9% to 5.7%). The rate of ED visits by TennCare beneficiaries decreased by -0.091 ED visits/person/year (95% CI = -0.136 to -0.046) in the disenrollment period when controlling for time and seasonality. The rate of ED visits among the uninsured increased by 0.038 ED visits/person/year (95% CI = 0.011 to 0.065) in the postdisenrollment period when controlling for cubic time trend. The proportion of all TennCare ED visits that resulted in hospital admission did not change significantly between the two periods after adjusting for time trend and seasonality. The proportion of uninsured ED visits resulting in hospital admission, however, significantly increased after disenrollment by 2.0% (95% CI = 1.8% to 2.2%) and by 0.6% (95% CI = 0.0% to 1.2%) after adjusting for time and seasonality., Conclusions: The TennCare disenrollment of 2005 was associated with a modest decrease in the number of total ED visits in Tennessee. However, the payer mix among the Tennessee ED population shifted abruptly. The increased rate of ED visits by Tennessee's uninsured and the increased proportion of uninsured ED visits leading to hospital admission suggest an increased burden of illness in this highly vulnerable population., (© 2011 by the Society for Academic Emergency Medicine.)

Objective: In 2003, Oregon's Medicaid expansion program, the Oregon Health Plan (OHP), implemented premiums and copayments and eliminated outpatient behavioral health services. We ascertained whether these changes, including $50 copayments for emergency department (ED) visits, affected ED use., Methods: This study used statewide administrative data on 414,009 adult OHP enrollees to compare ED utilization rates (adjusted for patient characteristics) in 3 time periods: (1) before the cutbacks, (2) after the cutbacks, and (3) after partial restoration of benefits. We examined overall ED visits and several subsets of ED visits: visits requiring hospital admission, injury-related, drug-related, alcohol-related, and other psychiatric visits. Because the policy changes affected only the expansion program (OHP Standard), we ascertained the impact of these changes compared with a control group of categorically eligible Medicaid enrollees (OHP Plus)., Results: Compared with the control group, case-mix-adjusted ED utilization rates fell 18% among OHP Standard enrollees after the cutbacks. The rate of ED visits leading to hospitalization fell 24%. Injury-related visits and psychiatric visits excluding chemical dependency exhibited a similar pattern to overall ED visits. Drug-related ED visits increased 32% in the control group, perhaps reflecting the closure of drug treatment programs after the cutbacks reduced their revenue., Conclusion: The policy changes were followed by a substantial reduction in ED use. That ED visits requiring hospital admission fell to about the same extent as overall ED use suggests that OHP enrollees may have been discouraged from using EDs for emergencies as well as less-serious problems.

Objectives: Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children's hospital., Methods: This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child's home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children's hospital. The outcome variable was each child's ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations., Results: On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP., Conclusions: Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.

Objectives: In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use., Methods: This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use., Results: ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: -0.044, -0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes' drive had 0.26 (95% CI: -0.38, -0.13) fewer ED visits/person/yr., Conclusions: Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems-augmenting access to care and reducing reliance on EDs.

Study Objective: Federal policy changes and tightened state budgets may reduce Medicaid enrollment in many states. In March 2003, the Oregon Health Plan (Oregon's Medicaid expansion program) made substantial changes in its benefit package that resulted in the disenrollment of more than 50,000 beneficiaries. We sought to study the impact of these Oregon Health Plan policy changes on statewide emergency department (ED) use., Methods: In this observational study, hospital billing data on 2,680,954 visits to 26 Oregon EDs were obtained, sampled up to 24 months before and 24 months after the cutbacks. These visits represent approximately 62% of all visits to Oregon's 58 EDs. We ascertained counts of ED visits by payer group before and after the Oregon Health Plan cutback date, plus hospital admissions from the ED as a measure of acuity., Results: After the Oregon Health Plan policy changes, ED visits by the uninsured underwent an abrupt and sustained increase, from 6,682 per month in 2002 to 9,058 per month in 2004. Oregon Health Plan-sponsored and commercially insured visits decreased, resulting in a slight decrease in overall ED visits. Multivariable models adjusting for secular trends and seasonality showed a 20% (95% confidence interval 13% to 28%) increase in uninsured ED visits, whereas the adjusted number of Oregon Health Plan-sponsored visits decreased. The proportion of uninsured ED visits resulting in hospital admission increased (odds ratio 1.50; 95% confidence interval 1.39 to 1.62)., Conclusion: Oregon's Medicaid cutbacks were followed by increases in ED use and hospitalizations by the uninsured. Recent federal legislation facilitating similar Medicaid changes in other states may lead to replication of these events elsewhere.

Reductions in scope of benefits and stricter premium and co-payment policies in the Oregon Health Plan (OHP) led to a large drop in OHP enrollment. Outpatient psychiatric benefits were eliminated for approximately 25% of enrollees. One measure of access to care is ED use. We used administrative data from our ED from August 1, 2001, through June 30, 2004, comparing ED use before vs after the March 1, 2003, cutbacks. Before the cutbacks, 38% of ED visits were by OHP beneficiaries, falling to 32% afterward. Visits by the uninsured rose from 18% before to 22% afterward. The proportion of visits for psychiatric conditions covered by OHP fell from 41% [corrected] to 31% [corrected], although the proportion by uninsured patients rose from 16% to 23%. These findings suggest a worrisome reduction in access to medical care for uninsured Oregonians and unstable access for OHP enrollees, especially for behavioral health conditions.

Background: Many patients use emergency departments (EDs) for primary care. Previous studies have found that patient characteristics affect ED utilization. However, such studies have led to few policy changes., Objectives: We sought to determine whether Medicaid patients' ED use is associated with characteristics of their primary care practices., Research Design: This was a cohort study., Subjects: A total of 57,850 patients, assigned to 353 primary care practices affiliated with a Medicaid HMO, were included., Measures: Predictor variables were characteristics of primary care practices, which were measured by visiting each practice. The outcome variable was ED use adjusted for patient characteristics., Results: On average, patients made 0.80 ED visits/person/yr. Patients from practices with more than 12 evening hours/wk used the ED 20% less than patients from practices without evening hours. A higher ratio of the number of active patients per clinician-hour of practice time was associated with more ED use. When more Medicaid patients were in a practice, these patients used the ED more frequently. Other factors associated with ED use included equipment for the care of asthma and presence of nurse practitioners and physician assistants., Discussion: Modifiable characteristics of primary care practices were associated with ED use. Because the observational design of this study does not allow definitive conclusions about causality, future studies should include intervention trials to determine whether changing practice characteristics can reduce ED use., Conclusions: Improving primary care access and scope of services may reduce ED use. Focusing on systems issues rather than patient characteristics may be a more productive strategy to improve appropriate use of emergency medical care.

Objectives. We documented emergency department (ED) visits for nontraumatic dental problems and identified strategies to reduce ED dental visits. Methods. We used mixed methods to analyze claims in 2010 from a purposive sample of 25 Oregon hospitals and Oregon's All Payer All Claims data set and interviewed 51 ED dental visitors and stakeholders from 6 communities. Results. Dental visits accounted for 2.5% of ED visits and represented the second-most-common discharge diagnosis in adults aged 20 to 39 years, were associated with being uninsured (odds ratio [OR] = 5.2 [reference: commercial insurance]; 95% confidence interval [Cl] = 4.8, 5.5) or having Medicaid insurance (OR = 4.0; 95% Cl = 3.7, 4.2), resulted in opioid (56%) and antibiotic (56%) prescriptions, and generated $402 (95% Cl = $396, $408) in hospital costs per visit. Interviews revealed health system, community, provider, and patient contributors to ED dental visits. Potential solutions provided by interviewees included Medicaid benefit expansion, care coordination, water fluoridation, and patient education. Conclusions. Emergency department dental visits are a significant and costly public health problem for vulnerable individuals. Future efforts should focus on implementing multilevel interventions to reduce ED dental visits. [ABSTRACT FROM AUTHOR]

Objectives: The “emergency department algorithm” (EDA) uses emergency department (ED) diagnoses to assign probabilities that a visit falls into each of four categories: nonemergency, primary care–treatable emergency, preventable emergency needing ED care, and nonpreventable emergency. The EDA’s developers report that it can evaluate the medical safety net because patients with worse access to care will use EDs for less urgent conditions. After the Oregon Health Plan (OHP, Oregon’s expanded Medicaid program) underwent cutbacks affecting access to care in 2003, the authors tested the ability of the EDA to detect changes in ED use. Methods: All visits to 22 Oregon EDs during 2002 were compared with visits during 2004. For each payer category, mean probabilities that ED visits fell into each of the four categories were compared before versus after the OHP cutbacks. Results: The largest change in mean probabilities after the cutbacks was 2%. Attempts to enhance the sensitivity of the EDA through other analytic strategies were unsuccessful. By contrast, ED visits by the uninsured increased from 6,682/month in 2002 to 9,058/month in 2004, and the proportion of uninsured visits leading to hospital admission increased by 51%. Conclusions: The EDA was less useful in demonstrating changes in access to care than were other, simpler measures. Methodologic concerns with the EDA that may account for this limitation are discussed. Given the widespread adoption of the EDA among health policy researchers, the authors conclude that further refinement of the methodology is needed. [ABSTRACT FROM AUTHOR]