The Hilltop Institute was formerly the Center for Health Program Development and Management.

Emergency Room Use byIndividuals with Disabilities

Enrolled in Maryland’s HealthChoice Program

September 25, 2008

Prepared for the Maryland Medicaid

Advisory Committee

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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.

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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.

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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.

Why Focus on HealthChoice Enrollees with Disabilities?

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 Children 390,094 62.6% 121,044 220,054 55.2%

MCHP 128,403 20.6% 29,729 45,123 11.3%

Disabled 77,020 12.4% 34,450 112,466 28.2%

Other (Pregnant Women/SOBRA) 27,893 4.5% 10,301 20,725 5.2%

All HealthChoice 623,410 100.0% 195,524 398,368 100.0%

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

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

1.80

1.50

3.30

2.00 2.00

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

Families and Children

MCHP Disabled Other (SOBRA/Pregnant

Women)

All HealthChoice

Aver

age

ER

Visi

ts p

er E

nrol

lee

Coverage Group

Average Number of ER Visits by Coverage Group

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

9.2%

4.4%

24.9%

9.2%

11.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Families and Children MCHP Disabled Other (SOBRA/Pregnant

Women)

All HealthChoice

Perc

ent

Coverage Group

Percent of ER Visits that Led to an Inpatient Admission

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Demographic Characteristics of ER Users among Enrollees with Disabilities

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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.

Percent of Enrollees with at Least One ER Visit by Race (for HealthChoice Enrollees with Disabilities)

23.4%

46.6%44.2%

34.4%37.0%

44.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Asian African American White Hispanic Other All DisabledEnrollees

Race

Perc

ent

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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.

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

34.9%

43.3%

49.8%44.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

0-18 19-39 40-64 All

Perc

ent

Age Group

Percent of Enrollees with at Least One ER Visit by Age Group (for HealthChoice Enrollees with Disabilities)

Estimating Appropriate ER Utilization

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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 DisabilitiesEnrollees in the Non-Disabled

Coverage Groups All HealthChoice

ER Visits % ER Visits % ER Visits %

Monday 17,382 15.5% 43,708 15.3% 61,090 15.3%

Tuesday 17,295 15.4% 41,899 14.7% 59,194 14.9%

Wednesday 16,728 14.9% 41,533 14.5% 58,261 14.6%

Thursday 16,314 14.5% 39,831 13.9% 56,145 14.1%

Friday 15,638 13.9% 38,291 13.4% 53,929 13.5%

Saturday 14,413 12.8% 38,547 13.5% 52,960 13.3%

Sunday 14,696 13.1% 42,093 14.7% 56,789 14.3%

All 112,466 100.0% 285,902 100.0% 398,368 100.0%

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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).

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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.

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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 Code Description

Enrollees with Disabilities

All Other HealthChoice Coverage Groups

ER Visits % ER Visits %

99281ER Visit: Usually the presenting problems are self-

limited or minor 61,719 54.9% 188,168 65.8%

99282ER Visit: Usually the presenting problems

are of low to moderate severity 1,337 1.2% 6,819 2.4%

99283ER Visit: Usually the presenting problems

are of moderate severity 1,919 1.7% 8,554 3.0%

99284ER Visit: Usually the presenting problems

are of high severity 1,114 1.0% 2,591 0.9%

99285ER Visit: Usually the presenting problems

are of high or life-threatening severity 452 0.4% 480 0.2%

  Non-ER Specific Procedure Codes 44,783 39.8% 74,365 26.0%

  Missing Procedure Codes 1,142 1.0% 4,925 1.7%

All   112,466 100.0% 285,902 100.0%

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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 GroupNon- Emergent

Emergent, Primary CareTreatable

Emergent, ER CareNeeded,Preventable/Avoidable

Emergent,ER Care Needed,Not Preventable/Avoidable Injury

Psych, Drug,and Alcohol Unclassified Inpatient Total

Enrollees with Disabilities 16.5% 15.7% 6.4% 7.8% 12.6% 9.0% 7.1% 24.9% 100%

All Other HealthChoice Coverage Groups 24.8% 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.)

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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

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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.

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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 

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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.

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Contact Information

David IdalaResearch Analyst

The Hilltop InstituteUniversity of Maryland, Baltimore County (UMBC)

410.455.6296didala@hilltop.umbc.eduwww.hilltopinstitute.org