These conclusions are drawn from a trio of new studies by researchers at the University of Michigan Health System, which will be presented here May 7 at the annual meeting of the Pediatric Academic Societies. The Michigan results have implications for states across America, as they grapple with challenges, costs and changes in the Medicaid system.
The studies looked at the number of ER visits by children covered by Medicaid and private insurance, the urgency of their injury or illness, the appropriateness of their visiting the ER, and characteristics of their primary care, such as whether they had a regular doctor and whether they were referred to the ER by a doctor's office. The research was funded by the Michigan Department of Community Health, which runs the state Medicaid system, through an ongoing contract with the U-M Child Health Evaluation and Research, or CHEAR, Unit.
"Our data confirmed some of the trends that have been suspected, such as the use of the ER for non-urgent care, but some of our findings challenge common perceptions," says CHEAR research investigator Sarah J. Clark, M.P.H., senior author on the three studies. "For instance, because the shift to managed care has increased the number of Medicaid kids who have a primary care doctor or clinic to go to, or for their parents to consult about illnesses, they don't always have to rely on the ER as the first and only option. Their patterns of care are getting closer to what we see among children with private insurance."
The first study, led by research investigator Kevin Dombkowski, Dr.P.H., analyzed state Medicaid claims data from 2000, when most Medicaid beneficiaries were enrolled in managed care plans. Two companion studies, led by pediatric emergency medicine specialist Rachel M. Stanley, M.D., were based on interviews with 422 adults who accompanied children on visits to 13 Michigan ERs for low-urgency complaints; about half of the kids were covered by Medicaid.
Dombkowski's analysis of Medicaid claims found that 21 percent of children enrolled in Medicaid visited the ER at least once during the year 2000, and about 75 percent of their ER visits were for non-emergent problems.
Dombkowski then looked at the children’s Medicaid enrollment patterns, finding that 60 percent of children were enrolled in a Medicaid managed care plan for the entire year. The other 40 percent had some months of coverage under the traditional “fee-for-service” Medicaid structure, either because there was no managed-care Medicaid plan open in their area or because they were newly qualified for Medicaid and were awaiting plan enrollment.
By comparing ER visit rates among children enrolled in fee-for-service Medicaid and those in managed care, Dombkowski made an interesting discovery. "Kids who spent all of 2000 in fee-for-service Medicaid used the ER for non-emergent care 22 percent more often than children who had managed-care coverage the entire year," he explains. "Even those enrolled in fee-for-service for only part of 2000 came to ERs for emergent care 26 percent more often than those in managed care plans.""
The causes behind these trends become clearer with Stanley's research, which gathered information directly and anonymously from the 422 adults who brought children to 13 ERs throughout the state in 2001. All of the children had been triaged by ER staff as low-urgency cases, and all were over 6 months of age, to screen out nervous parents of newborns.
Stanley's research assistants used a structured interview format to interview parents as they came to the ER. Parents were asked about the symptoms and events that led them to bring the child to the ER, as well as the child's insurance status, age, gender, race, chronic conditions, and primary care and ER habits and history. In all, 52 percent of the children were on Medicaid, 45 percent had private insurance, and 3 percent had no insurance.
Even though the children in the sample had non-urgent problems and were low on the triage list, Stanley and Clark wanted to see if the ER was the right place for them — the "appropriateness" of their parents’ decision to go to the ER. So, Stanley and a non-physician independently reviewed what the parents said when asked about the child's condition and their decision to bring them to the ER.
They judged that the parent's decision to use the ER represented a logical choice for about half of the visits, despite the low urgency of the child's illness. There was no difference in appropriateness between Medicaid children and privately insured children.
This lack of a clear difference in appropriateness surprised the researchers. “We often hear the perspective that non-urgent ER visits represent inappropriate health care utilization. But when we took a closer look at parental decisions, we found that nearly half of these decisions were logical, based on the course of the illness or injury, and the parents’ sources of information and advice,” said Clark.
They also found little difference between Medicaid and non-Medicaid parents in the area of calling a doctor's office or other resource for advice before coming to the ER; the rate was around 40 percent for both. Among those who did call before taking a child to the ER, 68 percent of privately insured parents, and 51 percent of Medicaid parents, were told to go to the ER.
“Certain aspects of outpatient care seem to point parents to the ER," says Stanley. “For example, most pediatric offices do not have X-ray equipment, thereby limiting doctors’ ability to evaluate a possible bone fracture or other injury. Also important is the increasing hesitancy to give medical advice over the phone, primarily due to medicolegal issues.
“We found that when parents called for advice, they frequently ended up not with medical advice but with the choice of waiting for an appointment sometime in the future, going to the ER, or handling it themselves,” she continues. “If the child is very sick or uncomfortable, or has had a serious medical problem in the past, then the ER becomes a reasonable choice from the parent’s perspective."
Another encouraging trend found in the study, though one that still showed a gap between Medicaid and non-Medicaid children, was found in the percentage of adults who named a specific doctor when asked where their child went for routine care.
Eighty-seven percent of the adults with privately-insured children, and 74 percent of adults with Medicaid children, named a specific physician as their child's ‘regular doctor.’ This was viewed as good news by the researchers. "The proportion of Medicaid children with a regular doctor is more than we might have expected, and likely is a marker for increased access to primary care for this group" says Stanley.
Equally encouraging, there was no significant difference between the two groups in the proportion of children who had seen a primary care doctor in the last six months, nor in the percentage of parents who said they had had difficulty getting a primary care appointment. Regular primary care appointments have been shown to help reduce ER visits, especially in children with conditions that can prompt health emergencies, such as asthma.
Still, Stanley and Clark note that the ER seems to fit into a Medicaid parent's perception of the medical system differently than it fits into the perception of a privately insured parent. In their study, Medicaid children were more likely to have had at least one other ER visit that year (84 percent vs. 66 percent), and their parents were more likely to mention the ER when asked where they usually took a sick or injured child (59 percent vs. 42 percent). Any strategy to decrease ER use by Medicaid children will have to take that into account, they say.
"The ER is more on their radar screen, perhaps because of their family's historical patterns of use,” says Clark. “Traditionally, families have had problems finding doctors who accepted fee-for-service Medicaid; the ER was one of the few options available to them.“
She continues, “It appears that, with managed care, families now can identify their children’s regular doctor, they are taking children for regular doctor visits, and they are beginning to use the ER in a manner similar to privately insured children. In that sense, there seems to be a re-education of parents happening through Medicaid managed care. "But it will take time — time, and consistent provider participation — to create lasting changes in ER utilization."