- Email: [email protected]
230 Payment Received for Low Acuity Care
Research Forum Abstracts complaints at the academic hospital through campus specialty clinics, the burden on ED staff to write more prescriptions was minimal. However, the ED in the community setting saw an increase in the prescribing of scheduled drugs, suggesting patients were unable to receive scheduled medication prescriptions from neighboring clinics after the PDMP mandate.
228
The Repeal of Connecticut Sunday Alcohol Sale Restrictions did not Increase Emergency Department Visitation
Lord K, D’Onofrio G, Venkatesh A/Yale University School of Medicine, New Haven, CT; Yale University School of Medicine, New Haven, CT; Yale University School of Medicine, New Haven, CT
Background: The US Preventative Task Force has recommended limiting days of alcohol sales to reduce alcohol-associated harm. On May 14, 2012, the Connecticut State Legislature allowed for the previously banned alcohol sales to occur on Sunday statewide. Previous studies have shown mixed results regarding the health harms of increased alcohol sales but none have evaluated the effect on emergency department visitation. Study Objective: We first sought to determine whether repeal of a law permitting alcohol sales on Sunday would increase the amount of primary alcohol-related visits to the emergency department. Methods: We conducted a retrospective, cross sectional analysis of all ED visits from May 13, 2010 to May 13, 2013 in an academic, urban ED. Patients were included if they had a principal discharge diagnosis consistent with alcohol intoxication or alcohol withdrawal. The primary was the total number of daily visits with a principal alcohol-related diagnosis. The secondary outcome was total daily visits for alcohol withdrawal. To assess the impact of the law repeal, we first present descriptive statistics using the t-test (alpha 0.05) on the primary outcome for both Sunday and Tuesday, as the latter should not have been impacted by the law. We then constructed a difference-in-difference (DD) regression model to estimate the incremental number of visits attributable to the law while accounting for secular trends. Results: Over the three-year period, we identified a total of 10,862 visits, of which 9,576 were for uncomplicated alcohol intoxication and 1,286 for alcohol withdrawal. Our patient population consisted mostly of white (56%), middle age (mean 41.5 years) men (76%). Most patients were insured by Medicaid (52%), with the next largest insurance status being uninsured or self-pay (17%). There were an average of 6.49 visits per day with 5.72 for uncomplicated alcohol intoxication and 0.76 for withdrawal. Average pre- and post-Sunday visits were found to increase from 9.8 to 12.3 (P<.00). Using the DD model to account for secular trends, visits for primary alcohol-related visits saw a relative increase of 1.55 (P¼.086) visits on Sundays in comparison to Tuesday between the pre and post periods. Average Sunday ED visits for alcohol withdrawal did not significantly increase between the pre- and post- periods in both unadjusted (pre: 1.67 versus post: 1.89, P¼.22) as well as DD analysis (beta: -0.116, P¼.63). Conclusion: While we found increasing daily visits for alcohol intoxication in the period following repeal of a Sunday alcohol sales ban in CT, this difference was not present after accounting for secular trends. However, future analyses of alcohol repeal laws utilizing statewide data and broader inclusion criteria may a detect different effect of alcohol availability on ED utilization.
EMF-229
Impact of Decreased County Mental Health Services on the Emergency Department
Nesper AC, Morris BA, Holmes JF/University of California, Davis Medical Center, Sacramento, CA
Study Objectives: Government-provided mental health services are frequently being decreased, and the impact of community resource reductions on the emergency department (ED) is poorly understood. We aim to evaluate the impact of decreasing county mental health services in the ED. Methods: This is a retrospective before-and-after study at an urban, university hospital to measure the impact of decreasing county mental health services on the ED. On October 1, 2009, the county outpatient psychiatric evaluation unit closed, and county inpatient capabilities were decreased by 50%. Electronic health record data for ED visits for the 12 months prior to the decrease in county services (October 2008 to September 2009) were compared to the 12 months following the decrease (October 2009 to September 2010). All adult patient visits ( 18 years) evaluated for a psychiatric problem by a licensed clinical social worker were included. Outcome
S82 Annals of Emergency Medicine
measures included the number of patients evaluated for a psychiatric problem and the ED length of stay (LOS) for those patients. Results: A total of 97,126 adult ED visits occurred during the 2-year study period including 2,407 (2.5%) patient visits with a psychiatry consultation. The median age was 39 years (IQR 28, 49). Men were more likely to present in the period after the closure (885/1635, 54.1% (95% CI 51.7%, 56.6%)) than before the closure (377/ 772, 48.8% (95% CI 45.2%, 52.4%)), P¼.015. The mean number of daily psychiatry consults increased from 2.1 (95% CI 1.9, 2.3) before the closure to 4.5 (95% CI 4.3, 4.7) after the closure, difference in means 2.4 (95% CI 2.1, 2.7), P<.0001. Average ED LOS for psychiatry consultation patients was significantly longer after the closure (21.0 hours (95% CI 19.4, 22.6)) than before the closure (15.7 hours (95% CI 12.9, 18.5)), difference in means 5.3 hours (95% CI 2.2, 8.3), P¼.0016. Conclusion: The number of visits and the ED LOS for patients undergoing psychiatric consultation in the ED increased significantly following a decrease in county mental health services. The impact of decreasing governmental psychiatric services should be evaluated prior to the implementation of policy changes.
230
Payment Received for Low Acuity Care
Schneider S, Crane P, Sama A/North Shore University Hospital/ Hofstra School of Medicine, Manhasset, NY; University of Rochester, Rochester, NY; Good Samaritan, West Islip, NY
Background: Who bears the cost for low acuity ED patients? Over the past several years, many lawmakers have decried the high cost of minor care delivered in the emergency department (ED). They have deemed this care “unnecessary” and contributing to the high cost of health care. The CDC statistics suggest that 8% of ED visits are non-urgent. Some insurers in New York have promoted that 20% of ED visits are “unnecessary”. Most published studies on health care cost use ED charges to calculate the potential savings from diverting these visits. However, if these patients were diverted away from the ED, the savings to the insurance companies, the government and private pay would be the amount of total collection (‘reimbursement’) that is paid to the hospital, not the hospital charge. Study Objective: To describe the total collection to a multihospital health care system for ED visits of patients with low acuity. Methods: The hospital billing data on discharged ED patients was acquired from 5 EDs in a large hospital system for the year 2012. This system represents community, urban and academic centers. For this study, we defined a low acuity ED visit as one with a low visit charge, and a priori defined 2 levels – the lowest 8% of charges (derived from the CDC statistics) and the lowest 20% (as declared by a NY State insurer). Simple descriptive statistics were used. Reimbursement was defined as total amount collected for the visit from all sources. Reimbursement rate was calculated as reimbursement divided by charges. IRB approval was obtained. Discharges were used as fees for admitted patients are rolled into the inpatient charge. Results: A total of 253,157 patients were discharged from the 5 EDs during 2012. The median charge was $2219 and median reimbursement was $550 (reimbursement rate 25%). No reimbursement was received for 3.7% of visits. The median charge for these unreimbursed visits was $2329 (max charge $57,581). Total amount of charges not reimbursed was over $1.9M. The lowest 8% of charges accounted for just 3.3% of all reimbursement dollars from any payer (their cost). The median charge for these visits was $962 and median reimbursement $152 (reimbursement rate 16%). The lowest 20% of charges accounted for 11.2% of reimbursement dollars by any payers (their cost). The median charge for these visits was $1130 and median reimbursement was $172 (reimbursement rate 15%). Conclusion: When constructing cost savings projections from diverting ED patients, it is important to use total reimbursement figures rather than hospital charges. Our study suggests that diverting patients, particularly to an alternative source of care with its additive cost, will do little to reduce health care expenditures. It also suggests that the true cost of these low acuity visits is largely borne by the hospital.
231
Lack of Price Transparency: Extreme Variations in Costs for Brand Name and Generic Prescription Drugs as a Barrier for Uninsured Patients
Sood N, Long Y, Terp S, Joyce G, Arora S/Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles, CA; University of Southern California School of Pharmacy, Los Angeles, CA; Keck School of Medicine of the University of Southern California, Los Angeles, CA
Study Objectives: Many emergency department (ED) patients are given prescriptions upon discharge. However, approximately 20% of prescriptions are
Volume 64, no. 4s : October 2014
228
The Repeal of Connecticut Sunday Alcohol Sale Restrictions did not Increase Emergency Department Visitation
Lord K, D’Onofrio G, Venkatesh A/Yale University School of Medicine, New Haven, CT; Yale University School of Medicine, New Haven, CT; Yale University School of Medicine, New Haven, CT
Background: The US Preventative Task Force has recommended limiting days of alcohol sales to reduce alcohol-associated harm. On May 14, 2012, the Connecticut State Legislature allowed for the previously banned alcohol sales to occur on Sunday statewide. Previous studies have shown mixed results regarding the health harms of increased alcohol sales but none have evaluated the effect on emergency department visitation. Study Objective: We first sought to determine whether repeal of a law permitting alcohol sales on Sunday would increase the amount of primary alcohol-related visits to the emergency department. Methods: We conducted a retrospective, cross sectional analysis of all ED visits from May 13, 2010 to May 13, 2013 in an academic, urban ED. Patients were included if they had a principal discharge diagnosis consistent with alcohol intoxication or alcohol withdrawal. The primary was the total number of daily visits with a principal alcohol-related diagnosis. The secondary outcome was total daily visits for alcohol withdrawal. To assess the impact of the law repeal, we first present descriptive statistics using the t-test (alpha 0.05) on the primary outcome for both Sunday and Tuesday, as the latter should not have been impacted by the law. We then constructed a difference-in-difference (DD) regression model to estimate the incremental number of visits attributable to the law while accounting for secular trends. Results: Over the three-year period, we identified a total of 10,862 visits, of which 9,576 were for uncomplicated alcohol intoxication and 1,286 for alcohol withdrawal. Our patient population consisted mostly of white (56%), middle age (mean 41.5 years) men (76%). Most patients were insured by Medicaid (52%), with the next largest insurance status being uninsured or self-pay (17%). There were an average of 6.49 visits per day with 5.72 for uncomplicated alcohol intoxication and 0.76 for withdrawal. Average pre- and post-Sunday visits were found to increase from 9.8 to 12.3 (P<.00). Using the DD model to account for secular trends, visits for primary alcohol-related visits saw a relative increase of 1.55 (P¼.086) visits on Sundays in comparison to Tuesday between the pre and post periods. Average Sunday ED visits for alcohol withdrawal did not significantly increase between the pre- and post- periods in both unadjusted (pre: 1.67 versus post: 1.89, P¼.22) as well as DD analysis (beta: -0.116, P¼.63). Conclusion: While we found increasing daily visits for alcohol intoxication in the period following repeal of a Sunday alcohol sales ban in CT, this difference was not present after accounting for secular trends. However, future analyses of alcohol repeal laws utilizing statewide data and broader inclusion criteria may a detect different effect of alcohol availability on ED utilization.
EMF-229
Impact of Decreased County Mental Health Services on the Emergency Department
Nesper AC, Morris BA, Holmes JF/University of California, Davis Medical Center, Sacramento, CA
Study Objectives: Government-provided mental health services are frequently being decreased, and the impact of community resource reductions on the emergency department (ED) is poorly understood. We aim to evaluate the impact of decreasing county mental health services in the ED. Methods: This is a retrospective before-and-after study at an urban, university hospital to measure the impact of decreasing county mental health services on the ED. On October 1, 2009, the county outpatient psychiatric evaluation unit closed, and county inpatient capabilities were decreased by 50%. Electronic health record data for ED visits for the 12 months prior to the decrease in county services (October 2008 to September 2009) were compared to the 12 months following the decrease (October 2009 to September 2010). All adult patient visits ( 18 years) evaluated for a psychiatric problem by a licensed clinical social worker were included. Outcome
S82 Annals of Emergency Medicine
measures included the number of patients evaluated for a psychiatric problem and the ED length of stay (LOS) for those patients. Results: A total of 97,126 adult ED visits occurred during the 2-year study period including 2,407 (2.5%) patient visits with a psychiatry consultation. The median age was 39 years (IQR 28, 49). Men were more likely to present in the period after the closure (885/1635, 54.1% (95% CI 51.7%, 56.6%)) than before the closure (377/ 772, 48.8% (95% CI 45.2%, 52.4%)), P¼.015. The mean number of daily psychiatry consults increased from 2.1 (95% CI 1.9, 2.3) before the closure to 4.5 (95% CI 4.3, 4.7) after the closure, difference in means 2.4 (95% CI 2.1, 2.7), P<.0001. Average ED LOS for psychiatry consultation patients was significantly longer after the closure (21.0 hours (95% CI 19.4, 22.6)) than before the closure (15.7 hours (95% CI 12.9, 18.5)), difference in means 5.3 hours (95% CI 2.2, 8.3), P¼.0016. Conclusion: The number of visits and the ED LOS for patients undergoing psychiatric consultation in the ED increased significantly following a decrease in county mental health services. The impact of decreasing governmental psychiatric services should be evaluated prior to the implementation of policy changes.
230
Payment Received for Low Acuity Care
Schneider S, Crane P, Sama A/North Shore University Hospital/ Hofstra School of Medicine, Manhasset, NY; University of Rochester, Rochester, NY; Good Samaritan, West Islip, NY
Background: Who bears the cost for low acuity ED patients? Over the past several years, many lawmakers have decried the high cost of minor care delivered in the emergency department (ED). They have deemed this care “unnecessary” and contributing to the high cost of health care. The CDC statistics suggest that 8% of ED visits are non-urgent. Some insurers in New York have promoted that 20% of ED visits are “unnecessary”. Most published studies on health care cost use ED charges to calculate the potential savings from diverting these visits. However, if these patients were diverted away from the ED, the savings to the insurance companies, the government and private pay would be the amount of total collection (‘reimbursement’) that is paid to the hospital, not the hospital charge. Study Objective: To describe the total collection to a multihospital health care system for ED visits of patients with low acuity. Methods: The hospital billing data on discharged ED patients was acquired from 5 EDs in a large hospital system for the year 2012. This system represents community, urban and academic centers. For this study, we defined a low acuity ED visit as one with a low visit charge, and a priori defined 2 levels – the lowest 8% of charges (derived from the CDC statistics) and the lowest 20% (as declared by a NY State insurer). Simple descriptive statistics were used. Reimbursement was defined as total amount collected for the visit from all sources. Reimbursement rate was calculated as reimbursement divided by charges. IRB approval was obtained. Discharges were used as fees for admitted patients are rolled into the inpatient charge. Results: A total of 253,157 patients were discharged from the 5 EDs during 2012. The median charge was $2219 and median reimbursement was $550 (reimbursement rate 25%). No reimbursement was received for 3.7% of visits. The median charge for these unreimbursed visits was $2329 (max charge $57,581). Total amount of charges not reimbursed was over $1.9M. The lowest 8% of charges accounted for just 3.3% of all reimbursement dollars from any payer (their cost). The median charge for these visits was $962 and median reimbursement $152 (reimbursement rate 16%). The lowest 20% of charges accounted for 11.2% of reimbursement dollars by any payers (their cost). The median charge for these visits was $1130 and median reimbursement was $172 (reimbursement rate 15%). Conclusion: When constructing cost savings projections from diverting ED patients, it is important to use total reimbursement figures rather than hospital charges. Our study suggests that diverting patients, particularly to an alternative source of care with its additive cost, will do little to reduce health care expenditures. It also suggests that the true cost of these low acuity visits is largely borne by the hospital.
231
Lack of Price Transparency: Extreme Variations in Costs for Brand Name and Generic Prescription Drugs as a Barrier for Uninsured Patients
Sood N, Long Y, Terp S, Joyce G, Arora S/Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles, CA; University of Southern California School of Pharmacy, Los Angeles, CA; Keck School of Medicine of the University of Southern California, Los Angeles, CA
Study Objectives: Many emergency department (ED) patients are given prescriptions upon discharge. However, approximately 20% of prescriptions are
Volume 64, no. 4s : October 2014