Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

Despite ACA, Emergency Department Visits Remain Numerous

Despite ACA implementation activity, 35.2 percent of adults with Medicaid coverage visited emergency departments in 2014.

- Although policymakers want to see the Affordable Care Act (ACA) lead to a reduction in visits to emergency departments, new data from the Centers for Disease Control & Prevention (CDC) raise concerns about the mandate’s real impact on the use of emergency services.

A large percentage of adults with Medicaid coverage continue to visit emergency departments.

In a recent report, CDC reveals many adults with Medicaid coverage are still turning to emergency departments for care. Individuals with Medicaid coverage are much more likely to go to emergency departments than those with private insured or no insurance.

The Commonwealth Fund argues that individuals with Medicaid coverage are not always able to access primary care and specialty care facilities in a timely manner. As a result, they turn to emergency departments as an alternative. CDC argues that Medicaid populations simply have more health needs.

“This higher rate of use may be related to more serious medical needs in the Medicaid population,” states the study of 26,825 adults between the ages of 18 and 64 years old.

In 2014, 18 percent of adults visited emergency departments one or more times, the CDC report revealed. That year, more than a third of adults with Medicaid coverage went to emergency departments, while the percentage individuals with private coverage was only at 14.3 percent. About 16 percent of uninsured adults went to emergency department.

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In 2014, 77 percent of patients went to emergency departments because their medical condition became serious. This group of patients mainly consisted of adults with Medicaid coverage. Twelve percent of patients visited emergency departments because their doctor’s office was not open. Adults with private coverage mainly made of this group.

A small percentage of patients visited emergency departments because they did not have access to other providers. This group was mainly made up of uninsured individuals.

Each year, about 20 percent of adults in the US seek healthcare at emergency departments. A significant portion of these adults receive coverage through Medicaid. The health conditions of adults in Medicaid coverage tended to be poorer than health conditions among those with private insurance or even the uninsured, the CDC report said.

There is a common misconception that adults with Medicaid go to emergency departments for non-emergencies. “There is a common perception among the public and policymakers that Medicaid enrollees predominately use EDs for routine care of minor ailments that could have been more appropriately cared for in a less expensive outpatient care setting. The facts support a more complex picture of ED use by Medicaid enrollees,” Health Policy Alternatives, Inc. said in a previously published report.  

Since the first full year that ACA was implemented, emergency department use has not changed drastically. Trends in 2014 were much similar to trends from 2013, CDC observed. Adults with Medicaid coverage continue to go to emergency departments much more than privately insured and uninsured individuals. However, the percentage of uninsured individuals going to emergency departments one or more times a year has decreased over time, CDC said.

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Determining how ACA implementation will affect emergency department use appears to be a challenging task with data among researchers on this topic varying widely.

“It has been difficult to predict the impact of the Affordable Care Act and the expansion of both private and Medicaid coverage on ER use, as current research in the area shows mixed results.” CDC said. While one research study will argue that increased use of healthcare coverage may increase emergency department use, another will argue that these effect won’t last long.

Changing dynamics of Medicaid populations could impact rates of emergency department visits, CDC pointed out. “The uninsured population eligible for Medicaid enrollment is less likely than current enrollees to have several chronic medical conditions,” the report said.

However, this population tends to have high rates of some health-risk behaviors.

Many policymakers are under the impression that the expansion of Medicaid will cause less emergency department use. Some believe that this expansion will increase primary care access and improve the overall health of Medicaid beneficiaries. “This would, in turn, lessen the need for these Medicaid beneficiaries to use the ED and reduce overall healthcare costs,” Health Policy Alternatives, Inc. said.

READ MORE: CMS Rule Addresses Medicare Fraud, Overpayment Compliance

“Concerns about the high cost of ER care relative to office-based care–particularly among adults with Medicaid–have led some state legislatures to try to reduce the number of non-emergency ER visits by increasing cost sharing or other payment strategies,” CDC said.

In the recent press release, Jay Kaplan, MD, President of ACEP, stressed the importance of emergency departments. He argued that they can provide patients with timely access to medical care. He also said that the US currently has a shortage of primary care physicians and many of them will not accept Medicaid patients because Medicaid pays inadequately.

“Instead of putting a moat around the nation’s emergency rooms and trying to keep people out, policymakers need to recognize the value of this model of medicine that people need and facilitate its use.” Kaplan said.

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