Two patient groups created by the Affordable Care Act (ACA) -- Medicare patients enrolled in federally designated patient-centered medical homes and people under age 26 who are allowed to remain on their parents' health insurance -- had slightly fewer emergency department visits than they had before health care reform. However, there was no change in the rate of the most expensive types of emergency visits: those that lead to hospitalization.
One study examined the rate of emergency department visits and hospitalizations for Medicare patients treated by patient-centered medical homes. (Primary care practices can receive special designation as patient-centered medical homes (PCMH) from the National Committee for Quality Assurance.) From 2008 to 2010, outpatient emergency department visits grew more slowly for Medicare patients being treated by PCMH practices than by non-PCMH practices. The rate of growth per 100 PCMH beneficiaries was 13 visits fewer for 2009 and 12 visits fewer for 2010. There was no effect on rates of inpatient hospitalization.
"The concept of 'medical homes' has been around since the 1960s and reviews of their effectiveness in improving health outcomes have been mixed," said lead study author Jesse Pines, MD, MBA, FACEP, at the George Washington University School of Medicine and Health Sciences in Washington D.C. "Our study shows that these models can have a positive effect on patients, as far as limiting outpatient emergency department use, but they don't seem to keep patients from being hospitalized, which is many times more expensive than ER visits. Further evaluation of medical homes is needed, particularly on patients who are most likely to benefit, such as those with multiple health problems, a compromised social situation or both."
Maria Raven, MD, MPH, FACEP of the University of California San Francisco, who wrote the companion editorial, cautions that "health care delivery is rarely simple and studying health care utilization is quite complex. The type of outpatient emergency department use that may be affected by PCMH practices is not a main driver of health care expenditures when compared to inpatient hospital admissions and skilled nursing care."
In a related study, the emergency department visit rate declined by 1.6 per 1,000 people among young adults (age 19 to 25) covered by their parents' private insurance plans. The decrease was concentrated among women, weekday visits, non-emergency conditions and conditions that could be treated outside the emergency department.
"The reductions in ER use among young people were quite specific to less severe conditions that could be handled in a primary care setting, which is not unexpected," said lead study author Yaa Akosa Antwi, PhD, of Indiana University-Purdue University in Indianapolis, Ind. "Overall, the reductions in ER use were modest, which suggests that even when the ACA is fully implemented, population-level changes in emergency department use may also be modest. Future research will be needed to assess the effect of coverage expansions on the broader range of adults who will gain coverage under the ACA in the next several years."
The papers "Emergency Department and Inpatient Hospital Use by Medicare Beneficiaries in Patient-Centered Medical Homes" and "Changes in Emergency Department Use Among Young Adults After the ACA's Dependent Coverage Provision," along with an accompanying editorial ("Patient-Centered Medical Homes May Reduce ED Use: What Does this Tell Us?"), were published online in Annals of Emergency Medicine.
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