Convincing the nation's most vulnerable citizens to avoid costly emergency department visits is proving harder than expected. A new study from the University of Iowa found improving access to affordable primary care reduced preventable hospital stays for black and Hispanics who receive both Medicare and Medicaid but failed to reduce the number of trips to the emergency department.
In fact, trips to the emergency department went up among all individuals who receive both Medicare and Medicaid, known as "dual eligible," regardless of race or ethnicity.
The study, which appeared July 7 online in Health Affairs, is the first to evaluate the relationship between receiving care at federally qualified health centers, or FQHCs, and the rate of hospital stays and emergency department visits for potentially preventable conditions among individuals who receive both Medicare and Medicaid, the majority of whom are members of racial or ethnic minority groups.
"We've found evidence that increased FQHC use among the dual eligible population might be a very good thing among certain groups of dual eligibles," said Brad Wright, an assistant professor in the Department of Health Management and Policy at the University of Iowa's College of Public Health and co-author of the study. "But it should not be a strategy we pursue until we understand more about the increased use of emergency department visits we observed."
However, a key finding suggests that federally qualified health centers can reduce disparities in preventable hospitalizations for some dual eligibles, Wright said.
FQHCs are standalone health care facilities that receive federal grants to administer care to underserved populations. According to The Kaiser Family Foundation in 2013, there were 14 FQHCs in Iowa, including Proteus Inc. (Migrant Health Center) in Des Moines and Siouxland Community Health Center in Sioux City.
Wright isn't sure why the number of emergency department visits increased among those studied but speculated it might be the same reason those who are dual eligible use a FQHC.
"It's always open and therefore more convenient, plus it offers one-stop shopping if they need services such as lab work and imaging tests," he says. "A potentially preventable hospitalization indicates a serious lack of care earlier in the progression of the condition. A potentially preventable ED visit, on the other hand, just indicates inappropriate use of the ED for something that could be done by a primary care doctor, but it's still care earlier in the process.
"So, in fact, the ED visits may end up preventing the hospitalizations, which is why the two results may be seen to move in different directions," Wright explained.
Researchers analyzed Medicare data from 2008 to 2010 for elderly and nonelderly disabled dual eligibles residing in primary care service areas with nearby federally qualified health centers.
According to the study, there were fewer hospitalizations for potentially preventable conditions, especially among blacks and Hispanics who used the FQHCs than among their counterparts who did not use them: 16 percent fewer and 13 percent fewer, respectively. The same was true for nonelderly disabled blacks and Hispanic whose use of FQHCs was associated with 3 percent fewer and 12 percent fewer potentially preventable hospital stays, respectively.
People with dual eligibility are of particular concern to policy makers and health care providers because they have substantial health care needs that often go unmet. That's because they often face barriers to accessing care that have little or nothing to do with having insurance or the ability to pay for services. For example, they might lack transportation or encounter doctors unwilling to accept the low reimbursement rates common to Medicare and Medicaid.
Whatever the obstacle, the dilemma often leads to preventable hospital stays and visits to emergency departments that might have been avoided had this vulnerable population received basic medical care earlier.
"The reason this population gets a lot of attention is because they tend to be in pretty poor health and tend to incur very high health care costs," Wright says. "In short, if we could figure out how to improve care for them, it would mean both better health outcomes for them and tremendous savings to the nation's health care expenditures."
Wright said the next step for researchers would be to look at patterns of use among dual-eligible individuals at FQHCs to see how that might affect a person's likelihood of experiencing a potentially preventable event.
Created in 1965 as part of U.S. President Lyndon Johnson's War on Poverty, federally qualified health centers use a sliding-scale of fees to serve all patients, regardless of their ability to pay and usually provide "enabling services," such as operating a shuttle bus or paying subway fare to overcome issues with transportation.
In 2013, some 1,202 FQHCs provided care to about 21.7 million people in the United States.
Wright said the Affordable Care Act includes substantial provisions in support of federally qualified health canters.
"It recognized that these are very important providers, and that they would be even more important in providing care -- increasing the capacity of the health care system -- as more people gained insurance coverage," he says. "For example, the program was permanently authorized, and funding was substantially increased."
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