1. The Hilltop Institute was formerly the Center for Health Program Development and Management. Emergency Room Use by Individuals with Disabilities Enrolled in Maryland’s HealthChoice Program September 25, 2008 Prepared for the Maryland Medicaid Advisory Committee

2. -2- Why Study Emergency Room Use? The ER is an inappropriate setting for routine primary and specialty care. Use of the ER for non-emergency treatment taxes its capacity and may delay treatment for patients who are seriously ill or injured. Reliance on the ER as a medical home runs counter to care continuity and makes delivery of preventive care less likely. ER use is expensive.

3. -3- Study Objectives Profile the use of ER services among non- elderly HealthChoice enrollees, with an emphasis on enrollees with disabilities. Estimate the rate of potentially avoidable ER use. Identify factors associated with frequent ER utilization.

4. -4- Study Design Study period: calendar year (CY) 2006. Data source: HealthChoice eligibility files, Maryland Medicaid claims, and encounter data. The cohort consists of any HealthChoice enrollees who had any period of MCO enrollment in CY 2006. The definition of an ER visit includes both visits that resulted in an inpatient admission and visits that did not. Logistic regression was employed to model the likelihood of an ER visit during the study period.

5. Why Focus on HealthChoice Enrollees with Disabilities?

6. Enrollees with disabilities made up 12% of the HealthChoice population but accounted for 28% of ER visits in the HealthChoice program. Coverage Group Number of HealthChoice Population by Coverage Group Distribution of Population by Coverage Group Number of HealthChoice Population with at Least One ER Visit (Number of Unique Users) Total Number of ER Visits by Coverage Group Distribution of ER Visits by Coverage Group Families and Children390,09462.6%121,044220,05455.2% MCHP128,40320.6%29,72945,12311.3% Disabled77,02012.4%34,450112,46628.2% Other (Pregnant Women/SOBRA)27,8934.5%10,30120,7255.2% All HealthChoice623,410100.0%195,524398,368100.0% -6-

7. -7- About 45% of enrollees with disabilities visited the ER at least once in CY 2006.

8. -8- Of all enrollees who had an ER visit, those with disabilities had the highest average number of visits (3.3 visits per user).

9. -9- ER visits by enrollees with disabilities were more likely to result in an inpatient admission.

10. -10- Demographic Characteristics of ER Users among Enrollees with Disabilities

11. -11- African-American and White enrollees with disabilities were more likely than other racial/ethnic groups to use the ER. In CY 2006: 92 percent of HealthChoice enrollees with disabilities were either African American (57%) or White (35%). They also had the highest ER use rate: 3.3 visits per user for African Americans and 3.4 for Whites.

12. -12- Enrollees in Baltimore City were more likely than enrollees in any other region of the state to visit the ER. Enrollees with disabilities residing in Baltimore City had the highest ER utilization rate (3.6 visits per user). Southern Maryland and Washington suburbs had the lowest rate of ER visits (2.8). Overall, HealthChoice enrollees in the disabled coverage group averaged 3.3 ER visits per user.

13. -13- Older enrollees with disabilities were more likely than those aged 18 and under to visit the ER.

14. Estimating Appropriate ER Utilization

15. -15- ER use does not appear to increase on weekends. ER Visits By Day of the Week among Disabled and Non-Disabled Coverage Groups as well as Overall HealthChoice Population, CY 2006 Day of the Week Enrollees with Disabilities Enrollees in the Non-Disabled Coverage GroupsAll HealthChoice ER Visits% % % Monday17,38215.5%43,70815.3%61,09015.3% Tuesday17,29515.4%41,89914.7%59,19414.9% Wednesday16,72814.9%41,53314.5%58,26114.6% Thursday16,31414.5%39,83113.9%56,14514.1% Friday15,63813.9%38,29113.4%53,92913.5% Saturday14,41312.8%38,54713.5%52,96013.3% Sunday14,69613.1%42,09314.7%56,78914.3% All112,466100.0%285,902100.0%398,368100.0%

16. -16- Compared to other HealthChoice coverage groups, enrollees with disabilities are more likely to access ambulatory care before and after an ER visit. 58% of ER visits by enrollees with disabilities* did not have an ambulatory care visit within 30 days before going to the ER (*compared to 63% of ER visits by enrollees in other HealthChoice coverage groups). 52% of ER visits by enrollees with disabilities* did not have an ambulatory care visit within 30 days after having an ER visit (*compared to 54% of ER visits by enrollees in other HealthChoice coverage groups).

17. -17- Methods of Identifying Potentially Avoidable ER Visits CPT procedure codes as a crude indicator of potentially preventable ER visits. Methodology developed by researchers and clinicians at NYU Center for Health and Public Service Research.

18. -18- About 55% of ER visits by enrollees with disabilities* are self-limited or minor (*compared to 66% of ER visits by all other HealthChoice coverage groups). CPT Procedure CodeDescription Enrollees with Disabilities All Other HealthChoice Coverage Groups ER Visits% % 99281 ER Visit: Usually the presenting problems are self- limited or minor61,71954.9% 188,16865.8% 99282 ER Visit: Usually the presenting problems are of low to moderate severity1,3371.2% 6,8192.4% 99283 ER Visit: Usually the presenting problems are of moderate severity1,9191.7% 8,5543.0% 99284 ER Visit: Usually the presenting problems are of high severity1,1141.0% 2,5910.9% 99285 ER Visit: Usually the presenting problems are of high or life-threatening severity4520.4% 4800.2% Non-ER Specific Procedure Codes44,78339.8% 74,36526.0% Missing Procedure Codes1,1421.0% 4,9251.7% All 112,466100.0% 285,902100.0%

19. -19- Using the NYU algorithm, approximately 38.6% of ER visits by enrollees with disabilities* were considered potentially avoidable (*compared to 55.8% of ER visits for all the other HealthChoice coverage groups). Coverage Group Non- Emergent Emergent, Primary Care Treatable Emergent, ER Care Needed, Preventable /Avoidable Emergent, ER Care Needed, Not Preventable /AvoidableInjury Psych, Drug, and AlcoholUnclassifiedInpatientTotal Enrollees with Disabilities16.5%15.7%6.4%7.8%12.6%9.0%7.1%24.9%100% All Other HealthChoice Coverage Groups24.8%23.5%7.5%7.0%20.1%2.3%8.3%6.5%100% Non-emergent - The patient's initial complaint, presenting symptoms, vital signs, medical history, and age indicated that immediate medical care was not required within 12 hours Emergent/Primary Care Treatable - Based on information in the record, treatment was required within 12 hours, but care could have been provided effectively and safely in a primary care setting. The complaint did not require continuous observation, and no procedures were performed or resources used that are not available in a primary care setting (e.g., CAT scan or certain lab tests) Emergent - ED Care Needed - Preventable/Avoidable - Emergency department care was required based on the complaint or procedures performed/resources used, but the emergent nature of the condition was potentially preventable/avoidable if timely and effective ambulatory care had been received during the episode of illness (e.g., the flare-ups of asthma, diabetes, congestive heart failure, etc.) Emergent - ED Care Needed - Not Preventable/Avoidable - Emergency department care was required and ambulatory care treatment could not have prevented the condition (e.g., trauma, appendicitis, myocardial infarction, etc.)

20. -20- Predictors of frequent ER use among enrollees with disabilities. The following characteristics were associated with frequent ER use (5 or more visits in CY 2006): Age: 19-64 Gender: Female Race/ethnicity: Whites and African Americans Location of residency: Baltimore City

21. -21- Limitations Study relies on administrative data only. No information on time of day ER visit occurred; the time variable would indicate whether physician offices were closed at time of ER use.

22. -22- Conclusion Enrollees with disabilities are more likely than other HealthChoice enrollees to use ER services. However, enrollees with disabilities Have the lowest rate of primary-care sensitive (potentially preventable) ER visits among HealthChoice coverage groups Have the highest rate of ER visits that lead to an inpatient admission, which suggests their ER utilization may be “more appropriate” than that of other HealthChoice populations

23. -23- About The Hilltop Institute The Hilltop Institute at the University of Maryland, Baltimore County (UMBC) is a nationally recognized research center dedicated to improving the health and social outcomes of vulnerable populations. Hilltop conducts research, analysis, and evaluation on behalf of government agencies, foundations, and other non-profit organizations at the national, state, and local levels.

24. -24- Contact Information David Idala Research Analyst The Hilltop Institute University of Maryland, Baltimore County (UMBC) 410.455.6296 didala@hilltop.umbc.edu www.hilltopinstitute.org