Will health insurance expansion cut ER use? U-M study in teens & young adults may help predict

As the nation's health care system prepares for uninsured Americans to gain health insurance coverage under the Affordable Care Act, a question hangs over crowded hospital emergency departments: Will the newly insured make fewer ER visits than they do today?

According to the results of a new University of Michigan Medical School study in teens and young adults, the answer likely reflects a balance of ER care versus clinic visits. While the number of ER visits will likely stay about the same, clinic visits will likely go up.

The results, from the first national study of its kind, are published in Academic Emergency Medicine by a team led by U-M emergency physician Adrianne Haggins, M.D., M.S. The work was funded by the Robert Wood Johnson Foundation Clinical Scholars Program at U-M, and used data from the National Center for Health Statistics at the Centers for Disease Control and Prevention.

The researchers looked at patterns of emergency and non-emergency outpatient visits made by adolescents between the ages of 11 and 18 in the years before and after a major expansion of public health insurance coverage for this group. They were especially interested in ER care, given that it is unclear how the demand for both types of ambulatory care will change nationally when insurance is provided.

The results show the impact of CHIP, or Children's Health Insurance Program, a federal/state program signed into law in 1997 that made it possible for near-poor children to receive state-sponsored insurance. More than 7 million children now have CHIP insurance, and it remains an option under the Affordable Care Act.

By comparing the national trends in adolescents' ER and outpatient visit numbers with those for young adults (ages 19-29) in the 1992-1996 pre-CHIP era, versus post-CHIP years 1999-2009, the team could gauge the impact of CHIP as a national source of new insurance coverage. Most states didn't allow such young adults to enroll in CHIP, making them a good comparison group in the pre-ACA era.

The researchers found:

Outpatient visits rose significantly among adolescents after CHIP went into effect, while young adults' outpatient visits were flat.

ER visits by adolescents stayed flat after CHIP went into effect, while ER visits by young adults rose.

The ratio of outpatient-to-ER visits rose among adolescents, but fell among young adults. A ratio such as this, which shows the balance between the types of care settings, could be useful for assessing the impact of insurance reforms.

“Looking at both emergency department visits and outpatient visits together is important,” says Haggins, a clinical lecturer in the U-M Department of Emergency Medicine. “When we're thinking about access to health care and insurance reform, insurers and hospitals can not solely focus on limiting the number of emergency visits – we have to make sure there's adequate access to alternative outpatient care.”

The new results, she says, suggest that CHIP did just that, making it easier for pre-teens and teens to get outpatient care while still keeping emergency care available. The study did not look at the appropriateness of the emergency visits.

Haggins also notes that the findings emphasize the importance of ensuring adequate outpatient capacity in the months and years after an insurance expansion. “If a newly insured patient has a hard time finding a provider who would accept their insurance, or getting appointments with the ones who will, there is a real possibility that we will continue to see them go to the emergency department.”

More understanding is needed about the factors that prompt patients to choose emergency care rather than outpatient appointments – such as convenience, expectations for care, demand for diagnostic tests, and habit, she says.

Confronting the force of habit may be a big factor in encouraging appropriate emergency room use by newly insured patients, she notes. “Accessing the ER is a cultural learned behavior partly because the public knows that the ER is always open if they have difficulty accessing care,” she says. “We have to offer them alternatives once they are there, and better understand what factors drive them there. We need to coordinate with other ambulatory settings to help patients find providers and be aware of alternative settings to change patterns of healthcare seeking.”

And, if the goal of reducing emergency visits is a priority, she says, then emergency providers and outpatient providers must work together to coordinate a patient's care after an emergency visit, including access to specialists when needed.

If we want to maintain ER access, we need to be creative in developing alternative ways for patients to get timely outpatient care. That helps us preserve access for patients who really need emergency care,” says Haggins.

The data for the study came from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS).

In addition to Haggins, the study was performed by Stephen Patrick, MD, MPH, MS, Sonya Demonner, MPH, and Matthew M. Davis, MD, MAPP. Haggins and Davis are members of the U-M Institute for Healthcare Policy and Innovation.

Reference: Academic Emergency Medicine, doi: 10.1111/acem.12236