Changes in insurance status and emergency department visits after the 2008 economic downturn.

As the U.S. economy began its downward trend in 2008, many citizens lost their jobs and, ultimately, their employer-sponsored health care insurance. The expectation was that many of the newly uninsured would turn to emergency departments (EDs) for their health care. This study was undertaken to determine, first, if changes in the insurance status of the general population were reflected in the ED insurance payer mix and, second, whether there was evidence of an increased reliance on the ED as a continuing source of health care for any payer group(s). This was a retrospective observational study using public data files from the National Hospital Ambulatory Medical Care Survey for Emergency Departments for years 2006 through 2010 (2008 ± 2 years). Changes in the relative proportions of ED visits funded annually by private insurance, Medicaid, Medicare, and self-pay (uninsured) were analyzed using a logistic model. Poisson regression was used to compare trends in the rates of ED visits for each payer type (i.e., number of ED visits per 100 persons with each insurance type). A linear spline term was used to determine if there was a change in each risk estimate after 2008 compared to the risk estimate before 2008. Before 2008, the odds of an ED visit being funded by private insurance increased by 4% per year (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 0.98 to 1.10; p = 0.15), but after 2008 the odds reversed, decreasing by nearly 10% per year (OR = 0.91, 95% CI = 0.85 to 0.97; p = 0.02). Medicaid-funded visits demonstrated opposite trends with a small decreasing trend of 2% per year before 2008 (OR = 0.98, 95% CI = 0.92 to 1.04; p = 0.52), followed by a significantly increasing trend of 20% per year after 2008 (OR = 1.20, 95% CI = 1.12 to 1.27; p = 0.001). The growth in Medicaid-funded ED visits was attributable to increased numbers of visits by both pediatric (<18 years old) and non-elderly adult (19 to 64 years old) patients. For both Medicaid and private insurance visits, the change in trend in 2008 was statistically significant (p < 0.001 and p = 0.004, respectively). Self-pay visits were fairly steady before 2008 and then increased by about 5% per year after 2008, but this was not statistically significant (OR = 1.05, 95% CI = 0.96 to 1.14; p = 0.46), nor was the change in trend (p = 0.29). The results for Medicare-funded visits were also small and not statistically significant. There was also evidence of increased reliance on the ED by Medicaid-funded patients based on the comparison of ED visit rates. After 2008, the incidence rate ratio (IRR) for Medicaid-funded visits increased by 10% per year (IRR = 1.10, 95% CI = 1.10 to 1.10; p < 0.001) while the IRR for the other three payer groups changed about 1% per year (IRR = 0.99, 95% CI = 0.99 to 0.099; p < 0.001), indicating an increasing utilization of the ED by patients with Medicaid-funded care. After 2008, Medicaid patients were more dependent on ED services than uninsured, Medicare, or privately insured patients. Medicaid patients made up an increasing proportion of ED patients, and the rate of usage of ED services by all ages of Medicaid patients was significantly greater than that of the other three payer groups.

Watts SH ，David Bryan E ，Tarwater PM 《-》

Health insurance status change and emergency department use among US adults.

Ginde AA ，Lowe RA ，Wiler JL 《-》

Association of Medicare and Medicaid insurance with increasing primary care-treatable emergency department visits in the United States.

Policymakers have increasingly focused on emergency department (ED) utilization for primary care-treatable conditions as a potentially avoidable source of rising health care costs. The objective was to determine the association of health insurance type and arrival time, as indicators of limited availability of primary care, with primary care-treatable classification of ED visits. This was a retrospective analysis of a nationally representative sample of 241,167 ED visits from the 1997 to 2009 National Hospital Ambulatory Medical Care Surveys (NHAMCS). Probabilities of ED visits being primary care-treatable were categorized based on the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The association of health insurance type and arrival time was determined with the average probability of the primary diagnosis being primary care-treatable using multivariable linear regression. Compared to privately insured visits, Medicaid visits had a 1.7% (95% confidence interval [CI] = 1.2% to 2.2%) and uninsured visits a 2.4% (95% CI = 1.9% to 3.0%) higher probability of primary care-treatable classification, while Medicare visits had a 1.4% (95% CI = 0.7% to 2.0%) lower probability during the overall study period. Compared to business hours, weekend visits had a 1.5% (95% CI = 1.0% to 2.0%) higher probability of being primary care-treatable during the overall study period. From 1997 to 2009, the overall adjusted probability of ED visits being primary care-treatable increased by 0.19% (95% CI = 0.10 to 0.28) per year. This probability increased at a rate of 0.52% per year for Medicare visits (95% CI = 0.38% to 0.65%), more than double that of Medicaid visits (0.25% per year, 95% CI = 0.13% to 0.37%). By contrast, there was no significant change from 1997 to 2009 in the average probability of ED visits being primary care-treatable by privately insured (0.05% per year, 95% CI = -0.07 to 0.16) or uninsured (0.00% per year, 95% CI = -0.12 to 0.13) individuals. These findings add to prior work that implicates insurance type and arrival time in the variation of primary care-treatable ED visits. Although primary care-treatable classification of ED visits was most associated with uninsured or Medicaid visits, this classification increased most rapidly among Medicare visits during the study period.

Pukurdpol P ，Wiler JL ，Hsia RY ，Ginde AA ... -  《-》

Children's health insurance status and emergency department utilization in the United States.

Luo X ，Liu G ，Frush K ，Hey LA ... -  《-》

Trends and characteristics of US emergency department visits, 1997-2007.

Tang N ，Stein J ，Hsia RY ，Maselli JH ，Gonzales R ... -  《-》