Out‐of‐Network Emergency Department Use among Managed Medicaid Beneficiaries

Background: Emergency department (ED) use is often seen as a source of excess health care spending, prompting managers to limit ED capacity in their health systems. However, if limited ED capacity in a delivery system leads patients to seek emergency care elsewhere, then health care quality and efficient management may be compromised within the system. Objective:The objective of this study was to explore the effect of the Veterans Health Administration (VHA) in-house ED clinician capacity on VHA community care (CC) ED claims. Methods:We used administrative data from the VHA to identify CC ED claims and Department of Veterans Affairs emergency physician (EP) capacity for 2014-2019.We used quasi-experimental instrumental variables approach with two different instruments: percent weekday federal holidays and VHA EP full-time equivalents (FTEs). We controlled for VHA ED variables such as ED wait times (door to triage, door to doctor, and door to admission) and demand variables such as alternative insurance coverage, driving time to VHA care, and demographic variables (employment, age, household income, race, gender, and VHA priority status).Results: After instrumenting for capacity with percent weekday federal holidays, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 61 CC ED claims per 10,000 enrollees. After instrumenting for capacity with EP FTE, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 48 CC ED claims per 10,000 enrollees. Both of these results are statistically significant at p < 0.001. Conclusions:Our findings imply that offering more in-house ED care, in the form of clinician capacity, can substantially reduce out-of-system ED use. The results may be of interest to integrated health care system managers who prefer their patients to stay within network. INTRODUC TI ONThe Veterans Health Administration (VHA), a division of the Department of Veterans Affairs (VA), is the largest integrated health care system in the United States. Emergency care is an important part of continuum of care at the VHA and over 100 VA Medical Centers (VAMCs) have an emergency department (ED). 1 Although VHA patients have generally "universal coverage" for preventative,

show abstract

“…[21][22][23] Another factor that has been commonly associated with decreased out-of-network ED use is increasing access to primary care. 14,24…”

Section: Discussionmentioning

confidence: 99%

“…To reduce ED use in the homeless population, we need to address psychosocial needs in addition to medical needs, in the form of increased social services like housing subsidies 21–23 . Another factor that has been commonly associated with decreased out‐of‐network ED use is increasing access to primary care 14,24 …”

Section: Discussionmentioning

confidence: 99%

Delivery system emergency department capacity and its effect on nonsystem service utilization

Tenso

Pizer

Palani

2023

Academic Emergency Medicine

View full text Add to dashboard Cite

show abstract

“…Smaller ACOs and health plans could expand their in‐network ED capacity by contracting with more ED hospitals and providers. However, the cost and benefits of such a strategy should be considered because expanding ED capacity can be a complex and expensive undertaking 11 …”

Section: Discussionmentioning

confidence: 99%

“…Increased spending also results from the duplicative services and overutilization that are frequent in out-of-system care. 9,10,11 In sum, despite choice and access advantages, out-of-system care leakage can decrease quality and increase adverse health outcomes and spending.…”

Section: Introductionmentioning

confidence: 99%

“…Health systems pay out‐of‐system providers more than the in‐house cost for similar care with no guarantee for quality of the purchased care. Increased spending also results from the duplicative services and overutilization that are frequent in out‐of‐system care 9,10,11 . In sum, despite choice and access advantages, out‐of‐system care leakage can decrease quality and increase adverse health outcomes and spending.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals

Palani

Garrido

Tenso

et al. 2023

Academic Emergency Medicine

View full text Add to dashboard Cite

Background: Care leakage from health systems can affect quality and cost of health care delivery. Identifying modifiable predictors of care leakage may help health systems avoid adverse consequences. Out-of-system emergency department (ED) use may be one modifiable cause of care leakage. Our objective was to investigate the relationship between out-of-system ED use and subsequent specialty care leakage. Methods: We used the Veterans Health Administration's (VA) Corporate Data Warehouse data from January 2021 to July 2021. A total of 330,547 patients who had at least one ED visit (in-house or community care [CC]) in the index period (January 2021-March 2021) were included. Outcomes were the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from the index ED visit.Instrumental-variables regressions, using VA ED physician capacity as an instrument for Veterans' CC ED use, were utilized to estimate the proportions of subsequent specialty care visits in the community. Estimates were adjusted for patient and facility characteristics.Results: A CC ED visit was associated with increases in the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from index visit. Within 30 days from index visit, CC ED patients were estimated to have a 45-percentage-point (pp; 95% confidence interval [CI], 43-47 pp) higher proportion of CC specialty care visits than patients with an in-house ED visit (p < 0.001). We observed similar, though slightly attenuated, results over long time periods since the index visit.Conclusions: Veterans who have a CC ED visit have a greater proportion of subsequent specialty care visits in CC hospitals and clinics than Veterans with a VA ED visit.This relationship persists when we examine Veterans whose decision to go to a CC ED is influenced by VA ED physician capacity rather than general preferences for CC.

show abstract

Frequent Users of 9-1-1 Emergency Medical Services: Sign of Success or Symptom of Impending Failure?

Raven¹,

Tangherlini²,

Hall³

2018

Prehospital Emergency Care

View full text Add to dashboard Cite

Out‐of‐Network Emergency Department Use among Managed Medicaid Beneficiaries

Cited by 7 publications

References 22 publications

Delivery system emergency department capacity and its effect on nonsystem service utilization

Delivery system emergency department capacity and its effect on nonsystem service utilization

Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals

Frequent Users of 9-1-1 Emergency Medical Services: Sign of Success or Symptom of Impending Failure?

Contact Info

Product

Resources

About