Sponsors
By: Jill Miyamura, PhD
8/6/2009
Emergency medical care is a legal right for all Americans, regardless of insurance status. Under a law enacted in 1986, emergency departments (EDs) must evaluate and stabilize anyone who shows up. That requirement -- bolstered by physicians' ethical duty to treat the ill -- has made hospital emergency departments subject to unique pressures.
There is growing concern that EDs will not be able to sustain care for all persons in the current economic environment. Between 2004 and 2008, there was a 29 percent increase in ED visits in Hawaii. A recent Institute of Medicine (IOM) report1 notes that EDs have become increasingly overcrowded, overburdened, and under-funded. Yet, little is known about who is paying for ED care, and how the uninsured affect ED utilization.
ED visit trends – insurance status matters
While the overall number of ED visits increased 29 percent between 2004 and 2008, significant differences exist in the increase of ED utilization between individuals with insurance and those without: the increase in the number of ED visits among the uninsured was twice that of the insured (45% increase versus 27% increase, respectively). As Hawaii’s economy worsens and the unemployment rate increases, the number of uninsured ED visits is expected to correspondingly increase, adding to Hawaii’s existing ED burden and under-funding.
Payer mix
In 2008, 366,834 visits were made to the ED, 12.6 percent of which resulted in hospital admission. The largest percentage (42 percent) of ED visits were billed to private insurance, followed by Medicaid/Quest (24 percent) and Medicare (22 percent). Uninsured ED visits accounted for 7.4 percent of all ED visits in Hawaii. Medicare, Medicaid/Quest, and self pay (uninsured) are considered high risk payers due to the fact that payments do not cover the cost of providing medical care. These high risk payers comprise 53.4 percent of the ED payer mix.
Payers of “treat and release” ED visits and ED visits resulting in hospital admission
Differences exist between payers on the likelihood that the ED visit will result in a hospital admission. Only 6.6 percent of uninsured ED visits result in a hospital admission, the lowest of all payers. Medicare had the highest hospital admission rate at 30 percent, followed by visits billed to private insurance (8.5 percent) and Medicaid (8.4 percent).
Population based rates – Insured versus uninsured
The treat and release ED visit rate among the uninsured (286 visits per 1,000 persons) was 1.2 times higher than the rate among the insured (240 per 1,000 persons). In comparison, the rate for visits resulting in hospital admission among the insured (37 visits per 1,000 persons) was 1.6 times higher than the rat among the uninsured (23 per 1,000 persons).
• Annual ED visit trend-overall
• Annual ED visit trend-uninsured
• Payer mix
• Discharge status
• Hospital Admissions (percent)
• Data table
HHIC Online Reports®, ED Database.
Treat-and-release ED visits
Treat-and-release ED visits were those ED visits in which patients are treated and released from that ED (i.e., they are not admitted to that specific hospital). While the majority of treat-an-release patients (96.3%) were discharged home, some were transferred to another acute care facility (1.6%), left against medical advice (1.2%), went to another type of long-term or intermediate care facility (nursing home or psychiatric treatment facility) (0.5%), referred to home health care (0.03%) or died (0.3%).
ED visits resulting in a hospital stay included those patients initially seen in the ED and then admitted to the same hospital.
Population rates are calculated using the number of ED visits as the numerator and population estimates as the denominator. The number of ED visits is obtained from HHIC’s ED database, while population estimates are obtained from Current Population Survey (CPS), U.S. Census Bureau. Rates are only an approximate estimate of the utilization in the population. The rates do not take into account multiple visits per person in the numerator. The uninsured rate for Hawaii (7.5%, 2007) was applied to the estimated population to compute population rates for the uninsured and insured.
Payer is the primary expected payer for the ED visit. To make coding uniform across all HCUP data sources, payer combines detailed categories into more general groups:
• Medicare includes fee-for-service and managed care Medicare patients.
• Medicaid includes fee-for-service and managed care Medicaid patients (QUEST).
• Private insurance includes HMSA, commercial carriers, and private HMOs and PPOs.
• Other includes Worker's Compensation, TRICARE/CHAMPUS, and other government programs.
• Uninsured includes an insurance status of "self-pay".
References
1 Institute of Medicine (IOM). Future of Emergency Care: Hospital-Based Emergency Care at the Breaking Point. Washington, DC: National Academies Press. 2007.
| Email this Article | Printer Friendly Version |
Additional Articles: