- Email: [email protected]
55: Trends in Charges and Payments for Outpatient Pediatric Visits to the Emergency Department from 1996-2003
Research Forum Abstracts and legal needs of uninsured patients seems imperative, however lawyers are rarely viewed as allies and ED providers are untrained to identify when legal help could correct conditions that exacerbate health problems. A pilot program was conducted to test the feasibility of providing free legal aid to uninsured patients in a busy urban ED setting. Methods: We conducted a 14 day program in 2006 in a large urban hospital ED from 3pm-11pm. Trained workers identified self pay patients at registration and after obtaining consent screened them for health insurance, financial/family stressors and nutritional needs. Psychiatric patients, trauma patients and medically unstable patients were excluded. Within 2 weeks of the ED visit, eligible consenting patients were contacted by lawyers to identify and address cases where legal proceedings were needed. Results: During the pilot 233 self pay patients presented to the ED. 140 (60%) were eligible for screening, 82 (59%) completed screening and agreed to be contacted by lawyers. The main reason for non completion of screening was pending health insurance. Health insurance problems identified were: lost coverage (53%), difficulty applying for coverage (20%). Financial/family stressors identified were: utility shut off (70%), debt collector calls (60%), possible eviction (45%), home repair problems (28%), rodent infestation (16%), and domestic violence (13%). 56(68%) patients needed nutritional aid. 82 patients were referred to the lawyers, of these 52% were successfully contacted. Follow up legal actions included: 7 patients referred for home repairs, and 2 Supplemental Security Income applications and 3 workman’s compensation proceedings initiated. Applications were completed for the following programs: 26 county Medicaid expansion, 11 food assistance, 10 Medicaid, 1 cash assistance. 25 patients received financial counseling. Conclusion: Patient advocacy through legal and medical support services was feasible in our ED setting. A future program has the potential to benefit both patients and hospitals by decreasing their financial burden and by correcting conditions that may aggravate health problems.
54
Implementation of Alert Protocols in the Emergency Department for Myocardial Infarction, Community Acquired Pneumonia and Acute Cerebrovascular Accident and its Impact on Core Performance Measures
Cassidy D, Papa L, Bryan J/Orlando Regional Medical Center, Orlando, FL
Study Objectives: In an attempt to improve quality of care and meet JCAHO standards for “core performance measures,” ED alert protocols and order sets with multidisciplinary participation were established for these diagnoses in January 2005 in our hospital. This study evaluated the impact of these ED alert protocols on JCAHO core performance measures for acute myocardial infarction, community acquired pneumonia, and acute cerebrovascular accidents. Methods: Retrospective analysis of a hospital core measures database from January 2005 to December 2006 at an academic urban hospital with an emergency medicine training program. Core performance measures as defined by JCAHO were assessed in patients with acute myocardial infarction (AMI), community acquired pneumonia (CAPA), and acute cerebrovascular accidents (CVA) presenting to the ED. Data was obtained on several indicators of quality of care performed in the ED for each diagnosis as defined by JCAHO. For AMI these included aspirin on arrival, beta-blocker on arrival, and time to cardiac catheterization intervention. For CAPA these included oxygen assessment, time to antibiotics within four hours, and proper initial antibiotic selection. For acute CVA consideration for Alteplase (tPA) and dysphagia assessment, was evaluated. Data from acute CVA was only available for October 2005 to August 2006. Data was analyzed using descriptive statistics and the Mann Whitney U Test. Results: Before protocols were implemented core performance measures for all categories combined were within 74.1% (95%CI⫽55.9-922.2) of the benchmarks and after 2-years of protocol implementation core measures had increased to 91.5% (95%CI⫽81.9-101.1) of the set benchmarks (P⫽0.028). For CAPA core measures, oxygenation consistently stayed at 100%, antibiotics within 4hrs increased from 52.5% to 67.7%, antibiotics selected went from 87.1% to 101.7%. For MI core performance measures ASA given went from 88.6% to 97.3%. beta-blockers 85.5% to 96.2% and interventional catheterization within 90 min from 45.3% to 99.8%. For CVA tPA considered went from 49.3% to 100%, assessment of dysphagia went from 22.4% to 60.2%. The greatest impact was seen during the second year of implementation of the protocols. Conclusion: Strategies to improve the ability to meet core performance measures are needed. Implementation of ED alert protocols and order sets improved the ability of this urban ED to meet JCAHO core performance measures. The application of such protocols to other hospitals and EDs would need further study.
S18 Annals of Emergency Medicine
55
Trends in Charges and Payments for Outpatient Pediatric Visits to the Emergency Department from 1996-2003
Hsia RY, MacIsaac D, Baker LC/Stanford University Hospital and Clinics, Stanford, CA; Stanford Department of Health Research and Policy, Stanford, CA; Stanford University Department of Health Research and Policy, Stanford, CA
Study Objectives: Pediatric visits to the emergency department (ED) - which constitute 1 in every 4 ED visits, or about 30 million pediatric visits annually - are thought to have a disproportionately negative impact on ED budgets, as children do not have access to Medicare coverage and thus, those without private insurance are either covered by Medicaid or uninsured. As healthcare access for children has been constrained by federal and state policy changes and there are reports of increased usage of the ED, it is important to understand the patient characteristics and reimbursement issues in safety net services, such as pediatric emergency care. Methods: We analyzed data from the Medical Expenditure Panel Survey (MEPS), collected by the U.S. Agency for Healthcare Research and Quality, for the years 1996-2003. Using the ED visit as the unit of analysis, this paper analyzed observations for ED visits from those younger than 18. Reflecting the importance of Medicaid coverage and high uninsurance rates among children, we compared visits by uninsured patients, those covered by Medicaid, and those insured privately. For each of these groups, we calculated total charges, total payments, and unpaid charges, as well as the ratio of total payments to total charges. We defined total charges as the aggregate of facility and physician charges. Total payments represent the sum of all payments to the facility and to providers treating the patient. In addition, we also computed mean charges and payments by insurance status, as well as created adjusted mean payment rates and charges to account for variation in patient characteristics between insurance groups. To achieve this, we estimated regression models with payments or charges as the dependent variable. To account for the highly skewed distributions of charges and payments, we estimated the regressions using a Generalized Linear Models approach, specifying a log transformation of the dependent variable and a Poisson variance structure. Results: Overall, the percentage of pediatric visits covered by private, Medicaid, or no insurance was 54%, 32%, and 13%, respectively. We show a concerning decrease in the payment ratio for children in all payer groups. Even after adjustment, visits for children covered by Medicaid in 1996 were 42% and declined to 35% in 2003; for those covered by private insurance, the rates fell from 74% to 58%; for the uninsured, from 52% to 44%. In terms of dollar costs of ED visits, in 2003, the mean charge of a Medicaid visit was $792; for a private visit, $952; and for the uninsured, $913. Conclusions: Nationwide, reimbursements for pediatric ED visits have declined dramatically in all payer groups. Our results raise the question of the viability of EDs (both pediatric and general) in the context of this phenomenon of decreased payments continues in the context of an increased demand for ED services.
56
Patient Characteristics By Source Of Admission: Who Is Affected When the ED Gets Crowded?
Smulowitz PB, Brown D, Camargo Jr. CA, Wolfe R/Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: While the causes of crowding are multifactorial, it is not clear which populations are most affected. The purpose of this study is to understand nationally which populations most use the ED for admission to the hospital, and therefore are more likely to be affected by crowding. Methods: Data were obtained from the National Hospital Discharge Survey on hospital admissions from 2001 - 2003 to determine the source of hospital admission: through the ED vs via another (non-ED) source. For different subgroups of age, gender, race, insurance status, and region, a Pearson’s chi-square was used to determine differences between groups, and multivariate logistic regression was performed to evaluate these groups as potential predictors of admission from the ED. Results: Patients utilizing the ED for hospital admission were more likely to be over 65 years old (47% vs 33% admitted via non-ED sources), black (13% vs 11%), and have Medicare as their insurance (49% vs 34%); all p⬍0.001. In a comparison of US regions, the Northeast was more likely to admit patients via the ED (25% vs 20%, p⬍0.001). Multivariate analysis identified the following predictors of admission from the ED: age 65⫹ (OR 6.89, 95%CI 6.63-7.16), black race (OR 1.36, 95%CI 1.33-1.40), public insurance (Medicare OR 1.18, 95%CI 1.15-1.22; Medicaid OR 1.38, 95%CI 1.34-1.42), and self-pay (OR 2.29, 95%CI 2.20-2.39).
Volume , . : September
54
Implementation of Alert Protocols in the Emergency Department for Myocardial Infarction, Community Acquired Pneumonia and Acute Cerebrovascular Accident and its Impact on Core Performance Measures
Cassidy D, Papa L, Bryan J/Orlando Regional Medical Center, Orlando, FL
Study Objectives: In an attempt to improve quality of care and meet JCAHO standards for “core performance measures,” ED alert protocols and order sets with multidisciplinary participation were established for these diagnoses in January 2005 in our hospital. This study evaluated the impact of these ED alert protocols on JCAHO core performance measures for acute myocardial infarction, community acquired pneumonia, and acute cerebrovascular accidents. Methods: Retrospective analysis of a hospital core measures database from January 2005 to December 2006 at an academic urban hospital with an emergency medicine training program. Core performance measures as defined by JCAHO were assessed in patients with acute myocardial infarction (AMI), community acquired pneumonia (CAPA), and acute cerebrovascular accidents (CVA) presenting to the ED. Data was obtained on several indicators of quality of care performed in the ED for each diagnosis as defined by JCAHO. For AMI these included aspirin on arrival, beta-blocker on arrival, and time to cardiac catheterization intervention. For CAPA these included oxygen assessment, time to antibiotics within four hours, and proper initial antibiotic selection. For acute CVA consideration for Alteplase (tPA) and dysphagia assessment, was evaluated. Data from acute CVA was only available for October 2005 to August 2006. Data was analyzed using descriptive statistics and the Mann Whitney U Test. Results: Before protocols were implemented core performance measures for all categories combined were within 74.1% (95%CI⫽55.9-922.2) of the benchmarks and after 2-years of protocol implementation core measures had increased to 91.5% (95%CI⫽81.9-101.1) of the set benchmarks (P⫽0.028). For CAPA core measures, oxygenation consistently stayed at 100%, antibiotics within 4hrs increased from 52.5% to 67.7%, antibiotics selected went from 87.1% to 101.7%. For MI core performance measures ASA given went from 88.6% to 97.3%. beta-blockers 85.5% to 96.2% and interventional catheterization within 90 min from 45.3% to 99.8%. For CVA tPA considered went from 49.3% to 100%, assessment of dysphagia went from 22.4% to 60.2%. The greatest impact was seen during the second year of implementation of the protocols. Conclusion: Strategies to improve the ability to meet core performance measures are needed. Implementation of ED alert protocols and order sets improved the ability of this urban ED to meet JCAHO core performance measures. The application of such protocols to other hospitals and EDs would need further study.
S18 Annals of Emergency Medicine
55
Trends in Charges and Payments for Outpatient Pediatric Visits to the Emergency Department from 1996-2003
Hsia RY, MacIsaac D, Baker LC/Stanford University Hospital and Clinics, Stanford, CA; Stanford Department of Health Research and Policy, Stanford, CA; Stanford University Department of Health Research and Policy, Stanford, CA
Study Objectives: Pediatric visits to the emergency department (ED) - which constitute 1 in every 4 ED visits, or about 30 million pediatric visits annually - are thought to have a disproportionately negative impact on ED budgets, as children do not have access to Medicare coverage and thus, those without private insurance are either covered by Medicaid or uninsured. As healthcare access for children has been constrained by federal and state policy changes and there are reports of increased usage of the ED, it is important to understand the patient characteristics and reimbursement issues in safety net services, such as pediatric emergency care. Methods: We analyzed data from the Medical Expenditure Panel Survey (MEPS), collected by the U.S. Agency for Healthcare Research and Quality, for the years 1996-2003. Using the ED visit as the unit of analysis, this paper analyzed observations for ED visits from those younger than 18. Reflecting the importance of Medicaid coverage and high uninsurance rates among children, we compared visits by uninsured patients, those covered by Medicaid, and those insured privately. For each of these groups, we calculated total charges, total payments, and unpaid charges, as well as the ratio of total payments to total charges. We defined total charges as the aggregate of facility and physician charges. Total payments represent the sum of all payments to the facility and to providers treating the patient. In addition, we also computed mean charges and payments by insurance status, as well as created adjusted mean payment rates and charges to account for variation in patient characteristics between insurance groups. To achieve this, we estimated regression models with payments or charges as the dependent variable. To account for the highly skewed distributions of charges and payments, we estimated the regressions using a Generalized Linear Models approach, specifying a log transformation of the dependent variable and a Poisson variance structure. Results: Overall, the percentage of pediatric visits covered by private, Medicaid, or no insurance was 54%, 32%, and 13%, respectively. We show a concerning decrease in the payment ratio for children in all payer groups. Even after adjustment, visits for children covered by Medicaid in 1996 were 42% and declined to 35% in 2003; for those covered by private insurance, the rates fell from 74% to 58%; for the uninsured, from 52% to 44%. In terms of dollar costs of ED visits, in 2003, the mean charge of a Medicaid visit was $792; for a private visit, $952; and for the uninsured, $913. Conclusions: Nationwide, reimbursements for pediatric ED visits have declined dramatically in all payer groups. Our results raise the question of the viability of EDs (both pediatric and general) in the context of this phenomenon of decreased payments continues in the context of an increased demand for ED services.
56
Patient Characteristics By Source Of Admission: Who Is Affected When the ED Gets Crowded?
Smulowitz PB, Brown D, Camargo Jr. CA, Wolfe R/Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: While the causes of crowding are multifactorial, it is not clear which populations are most affected. The purpose of this study is to understand nationally which populations most use the ED for admission to the hospital, and therefore are more likely to be affected by crowding. Methods: Data were obtained from the National Hospital Discharge Survey on hospital admissions from 2001 - 2003 to determine the source of hospital admission: through the ED vs via another (non-ED) source. For different subgroups of age, gender, race, insurance status, and region, a Pearson’s chi-square was used to determine differences between groups, and multivariate logistic regression was performed to evaluate these groups as potential predictors of admission from the ED. Results: Patients utilizing the ED for hospital admission were more likely to be over 65 years old (47% vs 33% admitted via non-ED sources), black (13% vs 11%), and have Medicare as their insurance (49% vs 34%); all p⬍0.001. In a comparison of US regions, the Northeast was more likely to admit patients via the ED (25% vs 20%, p⬍0.001). Multivariate analysis identified the following predictors of admission from the ED: age 65⫹ (OR 6.89, 95%CI 6.63-7.16), black race (OR 1.36, 95%CI 1.33-1.40), public insurance (Medicare OR 1.18, 95%CI 1.15-1.22; Medicaid OR 1.38, 95%CI 1.34-1.42), and self-pay (OR 2.29, 95%CI 2.20-2.39).
Volume , . : September