Aug. 6—Although Medicaid beneficiaries’ emergency department (ED) use is overwhelmingly sought for emergent conditions, it also frequently stems from a lack of access to other providers, according to a research analysis by Congress’ main advisory group for the program.

The Medicaid and CHIP Payment Access Commission (MACPAC) examined its own and others’ research to identify factors driving Medicaid enrollees to seek ED care at higher rates than either privately insured or uninsured people. MACPAC reported earlier this year that 36 percent of pre-Medicare adult enrollees visited an ED in 2012.

The group of advisers concluded that only 10 percent of pre-Medicare age adult Medicaid beneficiaries sought ED care for nonemergent conditions—a similar proportion as privately insured patients.

However, MACPAC reported this year that about 25 percent of Medicaid beneficiaries sought such care not due to the urgency of their health condition, but because they could not access another provider. An even higher share of all Medicaid enrollees—one-third of adults and 13 percent of child enrollees—reported barriers in finding a physician or delays in getting needed care, MACPAC found.

The lack of access to another provider came despite “nearly all” beneficiaries reporting a usual place of care other than the ED, according to the report.

Generally, the reasons for delays in getting needed care included “trouble getting through to the practice by phone or reaching a doctor after hours, difficulty getting an appointment soon enough, language barriers, and lack of transportation.”

Among the one in four who explained that their ED visit resulted solely from a lack of provider access, reasons for their lack of access included that a health issue “occurred at night or on a weekend” and that the “doctor’s office/clinic was closed.” Such ED users did not include beneficiaries taken to the ED by ambulance, those whose physicians advised them to go to the ED, or those whose visit resulted in an admission.

Access Challenges Remain

Although Medicaid enrollees who experience barriers to primary care are more likely to report ED use, both Medicaid and privately covered patients reported lower ED usage when they had after-hours access to primary care practices.

The MACPAC report highlighted the need for after-hours access to primary care; however, it remains unclear to what extent after-hours care would address the provider access problem. For instance, the report noted evidence that some frequent ED users appear to receive inadequate primary or specialty care.

“Frequent use of the ED stems from a constellation of psychosocial and medical needs that cannot be addressed simply through primary care,” the report stated.

The report concluded that ED use is likely to remain relatively high in Medicaid until new delivery models are put in place to address the needs of frequent users.

Publication Date: Wednesday, August 06, 2014