This paper uses the 1997 and 1999 National Survey of America?s Families to explore how insurance coverage and access to care, along with other individual characteristics, are related to the large differences in Emergency Department (ED) use among the general population. People are classified into three ED use levels based on the number of visits over the 12 months prior to the survey: non-ED users (zero visits), occasional users (one or two visits), or frequent users (three or more visits). People in fair/poor health are 3.74 times more likely than others to be frequent ED users as compared to non-users. The uninsured and the privately insured adults have the same risk of being frequent users, but publicly insured adults are 2.08 times more likely to be frequent users. Adults who made three or more visits to doctors are 5.05 times more likely to be frequent ED users than those who made no such visits. It seems hard to blame the overcrowding of EDs on the uninsured. Instead, the publicly insured are over-represented of among ED users. Frequent ED users do not appear to use the ED as a substitute for their primary care and, in fact, are a less healthy population who need and use more care overall. (Medical Care 42(2): 176?82, February 2004.)

https://www.jstor.org/stable/pdfplus/4640715.pdf

Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter?

This paper considers the impact of community-level variables over and above the effects of individual characteristics on healthcare acess for low-income children and adults residing in large metropolitan statistical areas (MSAs). Further, we rank MSAs’ performance in promoting healthcare access for their low-income populations. The individual-level data come from the 1995 and 1996 National Health Interview Survey (NHIS). The community-level variables are derived from multiple public-use data sources. The out-come variable is whether low-income individuals received a physician visit in the past twelve months. The proportion receiving a visit by MSA varied from 63% to 99% for children and from 62% to 83% for adults. Access was better for individuals with health insurance and a regular source of care and for those living in communities with more federally-funded health centers. Children residing in MSA

http://healthpolicy.ucla.edu/publications/Documents/PDF/Access%20to%20Medical%20Care%20for%20Low%20Income%20Families%20How%20Do%20Communities%20Make%20a%20Difference.pdf

Access to medical care for low-income persons: how do communities make a difference?

After the passage of the Patient Protection and Affordable Care Act in March 2010 and the affirmation of its constitutionality by the Supreme Court in 2012, key decisions about the implementation of health care reform are now in the hands of states. But our understanding of these decisions is hampered by simplistic sortings of state directions into two or three simple, rigid categories. This article takes a different approach--it tracks the variations in relative state progress in implementing Medicaid expansion across a continuum of activities and steps in the decision-making process. This new measure reveals wide variation not only among states that have adopted Medicaid expansion but also among those that have rejected it but have also made progress. We use this new measure to spotlight cross-pressured Republican states that have adopted Medicaid expansion or have prepared to move forward and to explore possible explanations for implementation that extend beyond a simple focus on party control.

Why states expand Medicaid: party, resources, and history.

After the passage of the Patient Protection and Affordable Care Act in March 2010 and the affirmation of its constitutionality by the Supreme Court in 2012, key decisions about the implementation of health care reform are now in the hands of states. But our understanding of these decisions is hampered by simplistic sortings of state directions into two or three simple, rigid categories. This article takes a different approach—it tracks thevariations in relative state progress in implementing Medicaid expansion across a continuum of activities and steps in the decision-making process. This new measure reveals wide variation not only among states that have adopted Medicaid expansion but also among those that have rejected it but have also made progress. We use this new measure to spotlight cross-pressured Republican states that have adopted Medicaid expansion or have prepared to move forward and to explore possible explanations for implementation that extend beyond a simple focus on party control.

Report on Health Reform Implementation Why States Expand Medicaid: Party, Resources, and History

Examines best practices in care coordination for Medicare beneficiaries with chronic illnesses and recommends design options for a congressionally mandated demonstration.

Best Practices in Coordinated Care

This study examines the recent expansion of Medicaid managed care from the perspective of the thirteen states in the Urban Institute's Assessing the New Federalism project. States are moving to managed care for Medicaid both to improve beneficiaries' access and to control the growth in program costs. However, we find that despite dramatic growth in enrollment during this decade, few states are enrolling the elderly or the disabled—the most expensive Medicaid beneficiaries. We also conclude that cost-savings objectives are often at odds with goals of contracting with mainstream plans and protecting safety-net providers.

Medicaid Managed Care In Thirteen States

The management and outcomes of patients diagnosed with acute pulmonary embolism in primary care have not been characterized. To describe 30-day outcomes stratified by initial site-of-care decisions Multicenter retrospective cohort study Adults diagnosed with acute pulmonary embolism in primary care in a large, diverse community-based US health system (2013–2019) The primary outcome was a composite of 30-day serious adverse events (recurrent venous thromboembolism, major bleeding, and all-cause mortality). The secondary outcome was 7-day pulmonary embolism–related hospitalization, either initial or delayed. Among 652 patient encounters (from 646 patients), median age was 64 years; 51.5% were male and 70.7% identified as non-Hispanic white. Overall, 134 cases (20.6%) were sent home from primary care and 518 cases (79.4%) were initially referred to the emergency department (ED) or hospital. Among the referred, 196 (37.8%) were discharged home from the ED without events. Eight patients (1.2%; 95% CI 0.5–2.4%) experienced a 30-day serious adverse event: 4 venous thromboemboli (0.6%), 1 major bleed (0.2%), and 3 deaths (0.5%). Seven of these patients were initially hospitalized, and 1 had been sent home from primary care. All 3 deaths occurred in patients with known metastatic cancer initially referred to the ED, hospitalized, then enrolled in hospice following discharge. Overall, 328 patients (50.3%) were hospitalized within 7 days: 322 at the time of the index diagnosis and 6 following initial outpatient management (4 clinic-only and 2 clinic-plus-ED patients). Patients diagnosed with acute pulmonary embolism in this primary care setting uncommonly experienced 30-day adverse events, regardless of initial site-of-care decisions. Over 20% were managed comprehensively by primary care. Delayed 7-day pulmonary embolism-related hospitalization was rare among the 51% treated as outpatients. Primary care management of acute pulmonary embolism appears to be safe and could have implications for cost-effectiveness and patient care experience. 

/pdf/management-and-outcomes-of-adults-diagnosed-with-acute-203bzr38.pdf

Suresh Rangarajan

Papers

Medicaid Managed Care In Thirteen States

Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study

Treatment for Patients With Acute Pulmonary Embolism Diagnosed in Primary Care.