Comparison of Emergency Room Utilization for Non-Emergent Purposes Before and After the Implementation of the Affordable Care Act
Keywords:Emergency room utilization, nonemergent utilization, ER utilization, Affordable Care Act
AbstractThe implementation of the Patient Protection and Affordable Care Act (ACA) brought significant changes to the healthcare landscape. Many of the provisions of the ACA were intended to create greater access to healthcare services as well as to lower overall healthcare costs. One of the intentions of the ACA was to provide opportunities for patients to seek treatment at the appropriate level of care, i.e. primary care outpatient visits rather than emergency room (ER) utilization. The premise of this effort ostensibly was to lower healthcare costs by treating non-emergent illnesses at the lowest cost level. Additional provisions of the ACA such as mandated insurance coverage were intended to provide insurance coverage for patients to seek primary care services. Thus the cumulative impact of these provisions was predicted to increase access to primary care while simultaneously reducing non-emergent utilization of ER services. This study documents overall ER utilization as well as ER visits for non-emergent treatment before and after the implementation of the ACA. The analysis of the data revealed ER utilization increased in the five years after the ACA went into effect compared to the five-year period before the Act was implemented. In addition to the overall increase in ER visits, non-emergent visits also increased significantly during the same evaluation period. The study also revealed that Medicaid was the most common payer source for ER visits and unnecessary ER utilization rates were higher for rural hospitals than urban hospitals.
OSU Center for Health Systems Innovation. We analyze Cerner Health Facts data to improve clinical and financial outcomes. https://business.okstate.edu/chsi/what-we-do.html. Accessed November 27, 2017.
Taubman, S. L., Allen, H. L., Wright, B. J., Baicker, K., & Finkelstein, A. N. Medicaid increases emergency-department use: evidence from Oregon's Health Insurance Experiment. Science. 2014; 343:(6168): 263-268.
Browning, K. Medi-Cal patients flocking to ERs more than before ACA. California Healthline. https://californiahealthline.org/new/medi-cal-patients-flocking-to-ers-more-than-before-aca. Accessed November 27, 2017.
Northington, W. E., Brice, J. H., & Zou, B. Use of an emergency department by nonurgent patients. The American Journal of Emergency Medicine. 2005; 23(2): 131-137.
Howard, M. S., Davis, B. A., Anderson, C., Cherry, D., Koller, P., & Shelton, D. Patients' perspective on choosing the emergency department for nonurgent medical care: a qualitative study exploring one reason for overcrowding. Journal of Emergency Nursing. 2005; 31(5): 429-435.
Uscher-Pines, L., Pines, J., Kellermann, A., Gillen, E., & Mehrotra, A. Deciding to visit the emergency department for non-urgent conditions: a systematic review of the literature. The American Journal of Managed Care. 2013; 19(1): 47.
Pukurdpol, P., Wiler, J. L., Hsia, R. Y., & Ginde, A. A. Association of Medicare and Medicaid insurance with increasing primary careâ€“treatable emergency department visits in the United States. Academic Emergency Medicine. 2014; 21(10): 1135-1142.
Gandhi, S. O., Grant, L. P., & Sabik, L. M. Trends in non-emergent use of emergency departments by health insurance status. Medical Care Research and Review. 2014; 71(5): 496-521.
Carlson, J. N., Menegazzi, J. J., & Callaway, C. W. Magnitude of national ED visits and resource utilization by the uninsured. The American Journal of Emergency Medicine. 2013; 31(4): 722-726.
Hosseinichimeh, N., & Weinberg, S. The effect of the Massachusetts healthcare reform on emergency department use. World Medical & Health Policy. 2014; 6(1): 9-21.
Miller, S. The effect of insurance on emergency room visits: an analysis of the 2006 Massachusetts health reform. Journal of Public Economics. 2012; 96(11): 893-908.
Miller, S. The effect of the Massachusetts reform on health care utilization. INQUIRY:The Journal of Health Care Organization, Provision, and Financing. 2012; 49(4): 317-326.
Antwi, Y. A., Moriya, A. S., Simon, K., & Sommers, B. D. Changes in emergency department use among young adults after the Patient Protection and Affordable Care Actâ€™s dependent coverage provision. Annals of Emergency Medicine. 2015; 65(6): 664-672.
Wexler, R., Hefner, J. L., Sieck, C., Taylor, C. A., Lehman, J., Panchal, A. R., ... & McAlearney, A. S. Connecting emergency department patients to primary care. The Journal of the American Board of Family Medicine. 2015; 28(6): 722-732.
Weisz, D., Gusmano, M. K., Wong, G., & Trombley, J. Emergency department use: a reflection of poor primary care access? The American Journal of Managed Care. 2015; 21(2): 152-60.
Shippee, N. D., Shippee, T. P., Hess, E. P., & Beebe, T. J. An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs: financial and non-financial barriers have different associations. BMC Health Services Research. 2014; 14(1): 62.
Fisman, R. Straining Emergency Rooms by Expanding Health Insurance. Science. 2014; 343(6168): 252-253.
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