Characteristics of EDs serving high volumes of safety-net

populations

Catharine W. Burt , Ed.D.

Chief, Ambulatory Care Statistics Branch

July 13, 2004 Data Users Conference

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics

Topics

•Why do we care?

•What is the NHAMCS?

•What other data sources were used?

•What are the findings?

•So what?

“ Rising numbers of uninsured Americans, an increasing price-driven health care marketplace, and rapid growth in enrollment of Medicaid beneficiaries in managed care plans may have critical implications for the future viability of American’s health care safety net that serves a large portion of low-income and uninsured Americans.”

America’s Health Care Safety Net

...Institute of Medicine, 2000

What is the health care safety net?

•Emergency departments

•Public hospital systems

•Community health centers

•Rural health clinics

•Other clinics run by local health departments

What are the vulnerable populations?

•Uninsured persons

•Low income, under-insured persons

•Medicaid beneficiaries

•SCHIP beneficiaries

•Persons with special health care needs

Why are safety-net hospitals so concerned?

• Provide large amount of uncompensated care

• Increased Medicaid managed care increases their risk of under-compensation

• Decreased revenue from Medicare and private insurance

• Decreased Medicaid Disproportionate Share Hospital (DSH) payments from States

• Many hospitals and EDs closed

What are DSH payments?

•Federal matching to State giving

•History of creative funding

•1997 BBA reduced size of DSH payments

•2000 BIPA modified the DSH criteria

•MIUR > +1 sd in state

•> 1% MIUR (optional)

•>25% LIUR

Current study goals

•Use NHAMCS ED data to identify high-burden EDs.

•Use NHAMCS ED visit data, hospital information, and community factors to describe high-burden EDs in comparison to low-burden EDs.

•Describe which factors are most associated with high burden.

National Hospital Ambulatory Medical Care Survey (NHAMCS)

•Conducted annually since 1992

•Endorsed by emergency medicine associations

•Census Bureau — personal interview w/ medical record abstraction: 93% response

•Complex sample of 600 non-Federal, general & short stay hospitals Patient and visit characteristics for 25,611 ED encounters in 2000

•Hospital characteristics for 376 EDs

Other data sources

•HRSA’s Area Resource File

•State and county level data

•CMS’s Medicaid DSH payments for 2000

High safety-net ED definition

• If the ED met one or more of the following criteria

•>30% Medicaid patient visits

•>30% uninsured patient visits

•>40% combined Medicaid and uninsured

Distribution of hospital EDs by safety-net criteria: United States,

2000

9.4

7.7

2.1

17.0

63.9

High Medicaid/low uninsured

High Uninsured/low Medicaid

High both

High combined

Not Safety net

1 10 100Percent of hospital EDs

Distribution of hospital EDs by percent combined Medicaid & uninsured visits grouped by safety-net criteria: United

States, 200090+

85-8980-8475-7970-7465-6960-6455-5950-5445-4940-4435-3930-3425-2920-2415-1910-14

5-91-4

0

Percent of visits

0 2 4 6 8 10 12 14

Percent of hospital EDs

Met 2+ criteria for safety netMet 1 criteria for safety net

Met no criteria for safety net

Domains of ED characteristics studied

•Hospital

•Community

•Patient mix

•Diagnosis mix (Billings’ ACS algorithm)

•Visit severity, content, and outcome

Hospital:

Located in the South

Any Medicaid DSH payment

Medicaid DSH amount

Annual ED volume

Public owned

Medical school affiliation

Located in a non-metro area0 0.1 0.2 0.3 0.4 0.5-0.1

Correlation coefficient

Probability that an ED has high safety-net burden by geographic

region

SOURCE: CDC/NCHS

Northeast.25

South.61

West.24

Midwest.16

Distribution of EDs by geographic region according to

safety-net status

South

23%

South65%

Low safety net

High safety net

0% 20% 40% 60% 80% 100%

Percent of EDs

Northeast Midwest South West

Community:

Percent in poverty

Unemployment rate

State's DSH payment ratio

ED visit rate

HMO penetration rate

Income per capita

Primary care docs per pop

Percent age 65+

0 0.2 0.4 0.6-0.2-0.4Correlation coefficient

Patient Mix:

% Medicaid

% Uninsured

% Black or African American

% Child

% Medicaid risk plan

% Medicare

% Senior

0 0.2 0.4 0.6 0.8-0.2-0.4-0.6Correlation coefficient

Diagnosis mix:

% nonurgent

% emergent, primary care treatable

% mental health

% unclassified

% alcohol

% injury

% emergent, avoidable

% emergent, not avoidable0 0.1 0.2 0.3 0.4-0.1-0.2-0.3

Correlation coefficient

Comparison of diagnosis mix using Billings' algorithm by

safety-net status

16.9

19.3

8.1

12.4

32.8

2

8.5

21.2

21.3

7.3

10.7

28.1

1.9

9.6

Nonurgent *

Emergent, PC treatable *

Emergent, avoidable

Emergent, unavoidable *

Injury *

Mental health

Other diagnosis0 5 10 15 20 25 30 35 40

Percent of visits

Low safety net High safety net

* Difference is significant at p<.05* Difference is significant at p<.05

Visit severity, content, and outcome:

% of admits that are Medicaid % Left before being seen

% of admits that are uninsured Mean waiting time to see physician

% Resident/intern seen % Triaged as emergent or urgent

% No follow-up planned Mean drug mention rate

% of Medicaid patients admitted % Transfer to another facility

% arrive via ambulance % of uninsured patients admitted

% IV fluids administered % Admitted to hospital

0 0.2 0.4-0.2-0.4-0.6

Correlation coefficient

% of admits that are Medicaid % Left before being seen

% of admits that are uninsured Mean waiting time to see physician

% Resident/intern seen % Triaged as emergent or urgent

% No follow-up planned Mean drug mention rate

% of Medicaid patients admitted % Transfer to another facility

% arrive via ambulance % of uninsured patients admitted

% IV fluids administered % Admitted to hospital

Plot of bivariate correlation coefficients between ED characteristics and sizes of the

Medicaid and uninsured burdens

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Corr w. % Medicaid

0

0.2

0.4

0.6

-0.2

-0.4

Corr w. % Uninsured

Co-distribution of linear associations between ED characteristics and size of Medicaid and uninsured burdens

Characteristics in the + or - association cells are based on correlation coefficients that are significantly different from zero (p<.01).

- 0 +

-

0

+

Medicaid burden

Uni

nsur

ed b

urde

n

% senior% Medicare% admit to hospital% pop 65+Primary care doc per popACS % emergent, not

avoidable

ACS % emergent, avoidable% transferLocated in non-MSA area

ACS % nonurgentLocated in SouthState's DSH payment ratio% black or Afican American

ED visit rate% resident/internAny DSH paymentACS % emergnet, primary care

treatableUnemployment rate% childPercent in poverty% of admits that are Medicaid

% of admits that are uninsuredMean waiting time% left before being seen

% IV fluidsIncome per capita% injury% arrive via ambulance

remaining 12 characteristics

Role of DSH payments

• 41% of high-burden EDs receive payments compared with 25% of low-burden EDs

• State generosity is the highest determinant of whether a hospital receives a DSH payment

• State mean as standard puts hospitals in heavy-demand States at risk for no financial supplements

Probability that an ED received a Medicaid DSH payment by safety-net status and

region

SOURCE: CDC/NCHS

NortheastLSN=.50HSN=.64

SouthLSN=.28HSN=.33

WestLSN=.06HSN=.47

MidwestLSN=.20HSN=.56

Regional variation in rates of uninsured and Medicaid persons

under age 65: United States, 1998

15.9

13.6

20.621.8

11.7

9.210.1

11.3

Northeast Midwest South West0

5

10

15

20

25Rate per 100 persons

Uninsured Medicaid

SOURCE: A Shared Destiny (IOM 2003)

Comparison of percent distributions

Uninsured persons

Medicaid enrollees

High safety-net EDs

0% 20% 40% 60% 80% 100%

Northeast Midwest South West

Adjusted odds ratio for ED status of high safety net

Public South0.1

1

10

Odds ratio

State Medicaid DSH payment per Medicaid enrollee or uninsured person: United

States, 2000

SOURCE: CDC/NCHS

DSH per person$400+$200-399$100-199$50-99<$50Missing

So what?

• One-third of EDs carry a large burden of Medicaid or uninsured care, rarely both.

• Hospitals in the southern states are at greatest risk of having high safety-net EDs

• DSH payments help but vary widely across Nation.

• More Federal funding may be needed to distribute help more widely.