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Patient Insurance Profiles: A Tertiary Care Compared to Three Freestanding Emergency Departments
The Journal of Emergency Medicine, Vol. 51, No. 4, pp. 466–470, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2016.05.058
Administration of Emergency Medicine
PATIENT INSURANCE PROFILES: A TERTIARY CARE COMPARED TO THREE FREESTANDING EMERGENCY DEPARTMENTS Erin L. Simon, DO,*† Gregory Griffin, BS,* Kseniya Orlik, MD,* Zhenyu Jia, PHD,† Dave Hayslip, RN, BSN,* Daniel Kobe, BS,† and Nicholas Jouriles, MD*† *Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio and †Northeastern Ohio Medical University (NEOMED), Rootstown, Ohio Reprint Address: Erin L. Simon, DO, Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307
, Abstract—Background: It has been speculated that freestanding emergency departments (FEDs) draw more affluent, better-insured patients away from urban hospital EDs. It is believed that this leaves urban hospital based EDs less financially secure. Objective: We examined whether the distribution of patients with four types of insurance (self-pay, Medicaid, Medicare, and private) at the main ED changed after opening three affiliated FEDs, and whether the insurance type distribution was different between main ED and FEDs and between individual FEDs. Methods: A retrospective analysis of insurance status of all patients presenting to our EDs from July 2006 through August 2013. Insurance was divided into self-pay, Medicare, Medicaid, and private insurance across three time periods, which reflect the sequential opening of each FED. Insurance types for each facility were compared for individual time periods and across time periods. c2 was used to analyze the data. Results: In the three studied time frames (periods B, C, and D), there were less privately insured patients and more self-pay, Medicaid, and Medicare patients at the main than at each FED (p < 0.001). Insurance types were significantly different between each of the three FEDs and the main ED (p < 0.001) and between each of the three FEDs (p < 0.001). Conclusions: There were less privately
insured patients and more self-pay, Medicaid, and Medicare patients at the main ED compared to the FEDs. Privately insured patients decreased at both the FEDs and main ED during the study. Insurance distribution was significantly different between the main ED, and three FEDs, and between individual FEDs. Ó 2016 Elsevier Inc. All rights reserved. , Keywords—freestanding emergency department; insurance
INTRODUCTION The popularity and number of freestanding emergency departments (FEDs) has significantly increased in the past few years and continues to grow. It has been shown that these centers provide increased access and closer proximity emergency care to a greater number of patients through decreased travel time to an emergency facility (1). It has also been shown that FEDs have shorter ED wait times and lower acuity levels when compared to a tertiary care ED (2,3). Simon et al. examined the impact of opening two affiliated FEDs on patient volume at the main campus tertiary care center’s ED and found the combined patient volumes at all three facilities increased by 45%. This could potentially indicate an increase in access to care (4). Despite the evidence that FEDs potentially increase access to care, it has been speculated that they draw
Presented at the Midwest Regional Society for Academic Emergency Medicine; Oral Presentation, Akron, OH, 2013; International Conference on Emergency Medicine, Hong Kong, China, June 2014; Society for Academic Emergency Medicine, Dallas, TX, 2014.
RECEIVED: 30 December 2015; FINAL SUBMISSION RECEIVED: 28 April 2016; ACCEPTED: 6 May 2016 466
Patient Insurance Profiles at Freestanding EDs
467
Table 1. Time Periods Reflecting the Opening of the Three Freestanding Emergency Departments Period
Date
EDs Open
Before July 1, 2007 July 1, 2007 to July 31, 2009 August 1, 2009 to March 11,2012 After March 12, 2012
Main campus Main plus 1 FED Main plus 2 FEDs Main plus 3 FEDs
and FEDs and between individual FEDs and how that changed over time. METHODS
A B C D
FED = freestanding emergency department.
better-paying and more affluent customers away from more urban-based hospital EDs. It is believed that this leaves urban hospital based EDs less financially secure. This is because the percent of charges reimbursed vary according to insurance type. In the ED, Medicaid has the largest difference between the mean amount charged and received, followed by Medicare, private third-party payers, and self-pay (5). Furthermore, privately insured patients provide a higher reimbursement ratio per year compared to publically insured or self-pay patients (5). A previous study examined the acuity levels of patients presenting to FEDs compared to a tertiary care ED and found the average Emergency Severity Index level at the main ED was 3.04 compared to the three FEDs, which were 3.42, 3.22, and 3.38 (6). Because of this variation, it is important to understand the insurance profiles of patients visiting FEDs and trends that may be seen at nearby urban tertiary care center EDs. To our knowledge no prior study has evaluated the insurance profiles of patients seen at FEDs compared to an urban tertiary care center ED (main ED). Our goal was to determine the distribution of patient insurance profiles for a Level I trauma urban tertiary care center (main) ED and three associated FEDs. The three FEDs studied were located 9.6 miles north (FED1), 11.4 miles west (FED 2), and 11.8 miles south (FED 3) of the main ED. We examined whether the distribution of patients with four types of insurance (selfpay, Medicaid, Medicare, and private) at a main ED changed significantly after the opening of three affiliated FEDs. We also evaluated whether the insurance type distribution was significantly different between main ED
This retrospective study analyzed the insurance type of all patients presenting to the main ED and each of the three FEDs from July 2006 through August 2013. Insurance data were obtained from the hospital finance and billing department. Insurance categories were divided into self-pay, Medicaid, Medicare, and private insurance. We included military and Workers’ Compensation into private insurance. Period A (control) was July 2006 through June 2007, when only the main ED was open. Period B was July 2007 through July 2009, when one FED was open. Period C was August 2009 through February 2012, when two FEDs were open. Period D was March 2012 through August 2013, when three FEDs were open (Table 1). The Institutional Review Board approved this study. Data Analysis Monthly insurance percentages were determined for the main ED and FEDs from July 2006 through August 2013. A total of 211,161 encounters were examined. Monthly payer percentages were also determined for the control data from July 2006 through June 2007. c2 was used to evaluate insurance type over the four time periods. RESULTS The number of patients and insurance type for all EDs open in each time period were compared in Table 2. We found that overall for the health care system, self-pay and Medicare decreased slightly while private pay patients remained stable and Medicaid patients increased. We also compared all possible pairs of time periods using c2 test. The results revealed insurance type was different in the entire system across all time periods, and this was statistically significant (p < 0.001).
Table 2. Total Number of Patients and Insurance Type for the Entire System in Each Time Period Insurance Type Self-Pay
Medicaid
Medicare
Private
11,869 (0.1960263) 18,603 (0.1216518) 18,640 (0.1348604) 28,622 (0.1818817)
9,570 (0.1580564) 23,395 (0.1529885) 26,901 (0.1946287) 31,329 (0.1990837)
16,260 (0.2685473) 40,504 (0.2648705) 32,988 (0.2386682) 39,209 (0.2491580)
22,849 (0.3773700) 70,418 (0.4604891) 59,688 (0.4318427) 58,206 (0.3698766)
Values in parentheses represent the proportions in each time period.
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Table 3. Volume Numbers for Each Facility During the Time Frames Studied. Period A July 2006 through June 2007
Main ED total
Self-pay Medicaid Medicare Private Total
11,869 9,570 16,260 22,849 60,548
Period B July 2007 through July 2009
Main ED Total
FED 1 Total
Self-pay Medicaid Medicare Private Total
16,441 20,539 33,756 48,740 119,476
2,162 2,856 6,748 21,678 33,444
Period C August 2009 through February 2012 Self-pay Medicaid Medicare Private Total Period D March 2013 through August 2013 Self-pay Medicaid Medicare Private Total
Main ED Total
FED 1 Total
FED 2 Total
14,339 20,103 24,045 29,886 88,373
2,715 4,565 4,474 18,374 30,128
1,586 2,233 4,469 11,428 19,716
Main ED Total
FED 1 Total
FED 2 Total
FED 3 Total
18,918 19,877 24,720 19,819 83,334
4,364 4,683 5,142 16,196 30,385
2,896 3,013 5,842 12,716 24,467
2,444 3,756 3,505 9,475 19,180
FED = freestanding emergency department.
The results also showed the distribution of insurance types was significantly different between each of the three FEDs and the main ED (p < 0.001), as well as between each of the three FEDs (p < 0.001). Table 3 shows the volume of patients seen at each facility during the time frames studied. Table 4 reflects the changes in insurance during each time periods for individual EDs. We found that over time for each ED, there was an increase in self-pay patients, an increase in Medicaid patients, slight increases in Medicare patients for two EDs, and a decrease in privately insured patients. At the main ED, the insurance distributions for periods A to D were: self-pay 17.5% (n = 61,567); Medicaid 20% (n = 70,269); Medicare 28.1% (n = 98,781); and private 34.4% (n = 121,294). At the FEDs, the insurance distributions for periods B through D were: self-pay 10.4% (n = 16,437); Medicaid 13.4% (n = 21,106); Medicare 19.2% (n = 30,180); and private 57% (n = 89,876). These findings are represented in Figure 1. In the three studied time frames (periods B,
Table 4. Percentage of Patients with Various Insurance Types for Each Time Period Studied Variable
Self-Pay
Medicaid
Medicare
Private
Main ED (A) Main ED (B) Main ED (C) Main ED (D) FED #1 (B) FED #1 (C) FED #1 (D) FED #2 (C) FED #2 (D) FED #3 (D)
0.196 0.138 0.162 0.227 0.065 0.09 0.144 0.08 0.118 0.127
0.158 0.172 0.227 0.239 0.085 0.152 0.154 0.113 0.123 0.196
0.269 0.282 0.272 0.297 0.202 0.148 0.169 0.227 0.239 0.183
0.377 0.408 0.338 0.238 0.648 0.61 0.533 0.58 0.52 0.494
FED = freestanding emergency department.
C, and D), there were less privately insured patients at the main ED than individual FEDs (p < 0.001). The percentage of privately insured patients at the main ED decreased from 37.7% (period A) to 23.8% (period D) (p < 0.001). DISCUSSION This study looked at the insurance profile of patients presenting to the main ED and three FEDs from July 2006 to August of 2013. There was a notable difference in the patient payer status between the main ED and FEDs. The percentage of patients with private insurance presenting at the FEDs was 57% compared to 34.4% at the main ED. The number of privately insured patients decreased at both the main ED and the FEDs over the entire time frame studied. Medical, surgical, and intensive care unit admissions from our FEDs are directly admitted to our main hospital. Trauma transfers are sent to the main ED for trauma consultation. However, our FEDs have instructed local emergency medical services to take all trauma, ST-elevation myocardial infarction, and strokes to the main ED. The percentage of traumas requiring transfer to the main ED from our FEDs is approximately
Figure 1. Overall insurance status across all time periods studied. FED = freestanding emergency department.
Patient Insurance Profiles at Freestanding EDs
0.00002%, and we feel this was unlikely to affect our results. Our ST-elevation myocardial infarction patients go directly to the cardiac catheterization laboratory, bypassing the main ED. We had 11 patients with acute strokes during an 8-year period, who presented by private vehicle to our FED and were transferred to the main ED; this was also unlikely to affect our results. It is interesting to note the difference between patient insurance at our main ED from period A to period D. There was a marked overall change in private insurance patients at the main ED from 2006 to 2013, decreasing from 37.7% to 23.8%. However, from period A to period B, we actually saw an increase in privately insured patients at the main ED from 37.7% to 40.8% after the opening of the first FED. This might have been before the effects of the great economic recession, which might have contributed to the decrease that followed in periods C and D. We saw a large drop in privately insured patients from period B to D at FED 1, decreasing from 64.8% to 53.3%. Likewise, there was an increase in self-pay, Medicaid, and Medicare patients from 2006 to 2013. Previous studies have shown a similar trend during this time period showing slight decreases in private insurance and large increases of the amount of patients with Medicaid, Medicare, or simply no insurance (5). This might reflect the financial crisis of 2008, which resulted in changing insurance demographics of patients post recession. It might also reflect the start of the 2010 Affordable Care Act. The difference in payer status between the main ED and FEDs is noteworthy. The location of the FEDs, situated in suburban locations, and the main ED, in the middle of a downtown urban center, should be considered. Many critics believe FEDs treat very few self-pay and Medicaid patients. Our study shows that our FEDs see a large number of patients that are self-pay or Medicaid, ranging from 23% to 32% of FED patients in period D. Our results also show a larger percentage of privately insured patients at our FEDs compared to our main ED. Additionally, the insurance profiles of the main ED in 2006 2007, before any of the FEDs were open and the main ED in 2012 2013 were different with a decrease in private insurance and an increase in the Medicaid, Medicare, and self-pay patients. It is difficult to speculate whether the decrease in private insurance and increase in the uninsured and Medicaid patients at the main ED was due to increased presence of FEDs in the community or the changing economic climate after 2008. Several studies have suggested that the economic recession has caused an increase in the number of uninsured patients due to termination in the workplace and loss of benefits,
469
resulting in an increase in the uninsured seeking medical care at EDs (7). There has also been an increase in patients applying for Medicaid since the recession, up to 70% in some states (7). Our study highlights the increase in self-pay or uninsured patients at the main ED from 2006 to 2013. Previous studies have suggested that the uninsured may present with lower-acuity complaints and may utilize the ED as access for primary care needs (8). Limitations We can only report on trends seen in our data, and this study is subject to bias of a retrospective study, such as missing or inaccurate data. This study was conducted in one hospital system and may not be generalizable to other areas. Patients that visit the ED > 10 times in 1 year could also affect our results. This population represents 0.5% of our total patient population across all four EDs, and our study was not designed to measure their effect on the system. CONCLUSIONS During the three studied time frames (B, C, and D), there were fewer privately insured patients and more self-pay, Medicaid, and Medicare patients at the main ED compared to the FEDs. The number of privately insured patients decreased at both the main ED and FEDs during the study timeframe. The FEDs saw between 23% and 32% self-pay and Medicaid patients. REFERENCES 1. Henneman P, Garb J, Capraro G, et al. Geography and travel distance impact emergency department visits. J Emerg Med 2011;40:333–9. 2. Simon E, Kovacs M, Zhenyu J, et al. A comparison of acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med 2015;33:539–41. 3. Jouriles N, Simon EL, Griffin P, et al. Emergency department wait times are not always accurate. Acad Emerg Med 2013;20:421–3. 4. Simon EL, Griffin P, Jouriles N. The impact of two freestanding emergency departments on a tertiary care center. J Emerg Med 2012;43:1127–31. 5. Downey L, Zun LS, Burke T, et al. Who pays? How reimbursement impacts the emergency department. J Health Hum Serv Adm 2014; 36:400–16. 6. Simon E, Kovacs M, Jia Z, Hayslip D, Orlik K, Jouriles N. A comparison of acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med 2015;33:539–41. 7. Millard WB. Ignoring it isn’t an option: racial bias in emergency medicine. Ann Emerg Med 2009;53:A19–23. 8. Carlson JN, Menegazzi JJ, Callaway CW. Magnitude of national ED visits and resource utilization by the uninsured. Am J Emerg Med 2013;31:722–6.
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ARTICLE SUMMARY 1. Why is this topic important? Freestanding emergency departments (FEDs) are growing rapidly and currently represent 8% to 10% of EDs nationwide. Tertiary care EDs are vital to our ED landscape and their financial viability is important. Evaluating insurance trends at these facilities warrants further study. 2. What does this study attempt to show? This study attempts to show various insurance types of patients that present to three hospital-affiliated freestanding EDs and our main tertiary care ED. 3. What are the key findings? Overall for all time frames studied, private pay is the largest subset of insurance followed by Medicare, Medicaid, and self-pay at the main ED and FEDs. That changed at the main ED in period D, and Medicare became the largest insurance payer. 4. How is patient care impacted? FEDs may increase access to care for patients in the areas they service.
http://dx.doi.org/10.1016/j.jemermed.2016.05.058
Administration of Emergency Medicine
PATIENT INSURANCE PROFILES: A TERTIARY CARE COMPARED TO THREE FREESTANDING EMERGENCY DEPARTMENTS Erin L. Simon, DO,*† Gregory Griffin, BS,* Kseniya Orlik, MD,* Zhenyu Jia, PHD,† Dave Hayslip, RN, BSN,* Daniel Kobe, BS,† and Nicholas Jouriles, MD*† *Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio and †Northeastern Ohio Medical University (NEOMED), Rootstown, Ohio Reprint Address: Erin L. Simon, DO, Department of Emergency Medicine, Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307
, Abstract—Background: It has been speculated that freestanding emergency departments (FEDs) draw more affluent, better-insured patients away from urban hospital EDs. It is believed that this leaves urban hospital based EDs less financially secure. Objective: We examined whether the distribution of patients with four types of insurance (self-pay, Medicaid, Medicare, and private) at the main ED changed after opening three affiliated FEDs, and whether the insurance type distribution was different between main ED and FEDs and between individual FEDs. Methods: A retrospective analysis of insurance status of all patients presenting to our EDs from July 2006 through August 2013. Insurance was divided into self-pay, Medicare, Medicaid, and private insurance across three time periods, which reflect the sequential opening of each FED. Insurance types for each facility were compared for individual time periods and across time periods. c2 was used to analyze the data. Results: In the three studied time frames (periods B, C, and D), there were less privately insured patients and more self-pay, Medicaid, and Medicare patients at the main than at each FED (p < 0.001). Insurance types were significantly different between each of the three FEDs and the main ED (p < 0.001) and between each of the three FEDs (p < 0.001). Conclusions: There were less privately
insured patients and more self-pay, Medicaid, and Medicare patients at the main ED compared to the FEDs. Privately insured patients decreased at both the FEDs and main ED during the study. Insurance distribution was significantly different between the main ED, and three FEDs, and between individual FEDs. Ó 2016 Elsevier Inc. All rights reserved. , Keywords—freestanding emergency department; insurance
INTRODUCTION The popularity and number of freestanding emergency departments (FEDs) has significantly increased in the past few years and continues to grow. It has been shown that these centers provide increased access and closer proximity emergency care to a greater number of patients through decreased travel time to an emergency facility (1). It has also been shown that FEDs have shorter ED wait times and lower acuity levels when compared to a tertiary care ED (2,3). Simon et al. examined the impact of opening two affiliated FEDs on patient volume at the main campus tertiary care center’s ED and found the combined patient volumes at all three facilities increased by 45%. This could potentially indicate an increase in access to care (4). Despite the evidence that FEDs potentially increase access to care, it has been speculated that they draw
Presented at the Midwest Regional Society for Academic Emergency Medicine; Oral Presentation, Akron, OH, 2013; International Conference on Emergency Medicine, Hong Kong, China, June 2014; Society for Academic Emergency Medicine, Dallas, TX, 2014.
RECEIVED: 30 December 2015; FINAL SUBMISSION RECEIVED: 28 April 2016; ACCEPTED: 6 May 2016 466
Patient Insurance Profiles at Freestanding EDs
467
Table 1. Time Periods Reflecting the Opening of the Three Freestanding Emergency Departments Period
Date
EDs Open
Before July 1, 2007 July 1, 2007 to July 31, 2009 August 1, 2009 to March 11,2012 After March 12, 2012
Main campus Main plus 1 FED Main plus 2 FEDs Main plus 3 FEDs
and FEDs and between individual FEDs and how that changed over time. METHODS
A B C D
FED = freestanding emergency department.
better-paying and more affluent customers away from more urban-based hospital EDs. It is believed that this leaves urban hospital based EDs less financially secure. This is because the percent of charges reimbursed vary according to insurance type. In the ED, Medicaid has the largest difference between the mean amount charged and received, followed by Medicare, private third-party payers, and self-pay (5). Furthermore, privately insured patients provide a higher reimbursement ratio per year compared to publically insured or self-pay patients (5). A previous study examined the acuity levels of patients presenting to FEDs compared to a tertiary care ED and found the average Emergency Severity Index level at the main ED was 3.04 compared to the three FEDs, which were 3.42, 3.22, and 3.38 (6). Because of this variation, it is important to understand the insurance profiles of patients visiting FEDs and trends that may be seen at nearby urban tertiary care center EDs. To our knowledge no prior study has evaluated the insurance profiles of patients seen at FEDs compared to an urban tertiary care center ED (main ED). Our goal was to determine the distribution of patient insurance profiles for a Level I trauma urban tertiary care center (main) ED and three associated FEDs. The three FEDs studied were located 9.6 miles north (FED1), 11.4 miles west (FED 2), and 11.8 miles south (FED 3) of the main ED. We examined whether the distribution of patients with four types of insurance (selfpay, Medicaid, Medicare, and private) at a main ED changed significantly after the opening of three affiliated FEDs. We also evaluated whether the insurance type distribution was significantly different between main ED
This retrospective study analyzed the insurance type of all patients presenting to the main ED and each of the three FEDs from July 2006 through August 2013. Insurance data were obtained from the hospital finance and billing department. Insurance categories were divided into self-pay, Medicaid, Medicare, and private insurance. We included military and Workers’ Compensation into private insurance. Period A (control) was July 2006 through June 2007, when only the main ED was open. Period B was July 2007 through July 2009, when one FED was open. Period C was August 2009 through February 2012, when two FEDs were open. Period D was March 2012 through August 2013, when three FEDs were open (Table 1). The Institutional Review Board approved this study. Data Analysis Monthly insurance percentages were determined for the main ED and FEDs from July 2006 through August 2013. A total of 211,161 encounters were examined. Monthly payer percentages were also determined for the control data from July 2006 through June 2007. c2 was used to evaluate insurance type over the four time periods. RESULTS The number of patients and insurance type for all EDs open in each time period were compared in Table 2. We found that overall for the health care system, self-pay and Medicare decreased slightly while private pay patients remained stable and Medicaid patients increased. We also compared all possible pairs of time periods using c2 test. The results revealed insurance type was different in the entire system across all time periods, and this was statistically significant (p < 0.001).
Table 2. Total Number of Patients and Insurance Type for the Entire System in Each Time Period Insurance Type Self-Pay
Medicaid
Medicare
Private
11,869 (0.1960263) 18,603 (0.1216518) 18,640 (0.1348604) 28,622 (0.1818817)
9,570 (0.1580564) 23,395 (0.1529885) 26,901 (0.1946287) 31,329 (0.1990837)
16,260 (0.2685473) 40,504 (0.2648705) 32,988 (0.2386682) 39,209 (0.2491580)
22,849 (0.3773700) 70,418 (0.4604891) 59,688 (0.4318427) 58,206 (0.3698766)
Values in parentheses represent the proportions in each time period.
468
E. L. Simon et al.
Table 3. Volume Numbers for Each Facility During the Time Frames Studied. Period A July 2006 through June 2007
Main ED total
Self-pay Medicaid Medicare Private Total
11,869 9,570 16,260 22,849 60,548
Period B July 2007 through July 2009
Main ED Total
FED 1 Total
Self-pay Medicaid Medicare Private Total
16,441 20,539 33,756 48,740 119,476
2,162 2,856 6,748 21,678 33,444
Period C August 2009 through February 2012 Self-pay Medicaid Medicare Private Total Period D March 2013 through August 2013 Self-pay Medicaid Medicare Private Total
Main ED Total
FED 1 Total
FED 2 Total
14,339 20,103 24,045 29,886 88,373
2,715 4,565 4,474 18,374 30,128
1,586 2,233 4,469 11,428 19,716
Main ED Total
FED 1 Total
FED 2 Total
FED 3 Total
18,918 19,877 24,720 19,819 83,334
4,364 4,683 5,142 16,196 30,385
2,896 3,013 5,842 12,716 24,467
2,444 3,756 3,505 9,475 19,180
FED = freestanding emergency department.
The results also showed the distribution of insurance types was significantly different between each of the three FEDs and the main ED (p < 0.001), as well as between each of the three FEDs (p < 0.001). Table 3 shows the volume of patients seen at each facility during the time frames studied. Table 4 reflects the changes in insurance during each time periods for individual EDs. We found that over time for each ED, there was an increase in self-pay patients, an increase in Medicaid patients, slight increases in Medicare patients for two EDs, and a decrease in privately insured patients. At the main ED, the insurance distributions for periods A to D were: self-pay 17.5% (n = 61,567); Medicaid 20% (n = 70,269); Medicare 28.1% (n = 98,781); and private 34.4% (n = 121,294). At the FEDs, the insurance distributions for periods B through D were: self-pay 10.4% (n = 16,437); Medicaid 13.4% (n = 21,106); Medicare 19.2% (n = 30,180); and private 57% (n = 89,876). These findings are represented in Figure 1. In the three studied time frames (periods B,
Table 4. Percentage of Patients with Various Insurance Types for Each Time Period Studied Variable
Self-Pay
Medicaid
Medicare
Private
Main ED (A) Main ED (B) Main ED (C) Main ED (D) FED #1 (B) FED #1 (C) FED #1 (D) FED #2 (C) FED #2 (D) FED #3 (D)
0.196 0.138 0.162 0.227 0.065 0.09 0.144 0.08 0.118 0.127
0.158 0.172 0.227 0.239 0.085 0.152 0.154 0.113 0.123 0.196
0.269 0.282 0.272 0.297 0.202 0.148 0.169 0.227 0.239 0.183
0.377 0.408 0.338 0.238 0.648 0.61 0.533 0.58 0.52 0.494
FED = freestanding emergency department.
C, and D), there were less privately insured patients at the main ED than individual FEDs (p < 0.001). The percentage of privately insured patients at the main ED decreased from 37.7% (period A) to 23.8% (period D) (p < 0.001). DISCUSSION This study looked at the insurance profile of patients presenting to the main ED and three FEDs from July 2006 to August of 2013. There was a notable difference in the patient payer status between the main ED and FEDs. The percentage of patients with private insurance presenting at the FEDs was 57% compared to 34.4% at the main ED. The number of privately insured patients decreased at both the main ED and the FEDs over the entire time frame studied. Medical, surgical, and intensive care unit admissions from our FEDs are directly admitted to our main hospital. Trauma transfers are sent to the main ED for trauma consultation. However, our FEDs have instructed local emergency medical services to take all trauma, ST-elevation myocardial infarction, and strokes to the main ED. The percentage of traumas requiring transfer to the main ED from our FEDs is approximately
Figure 1. Overall insurance status across all time periods studied. FED = freestanding emergency department.
Patient Insurance Profiles at Freestanding EDs
0.00002%, and we feel this was unlikely to affect our results. Our ST-elevation myocardial infarction patients go directly to the cardiac catheterization laboratory, bypassing the main ED. We had 11 patients with acute strokes during an 8-year period, who presented by private vehicle to our FED and were transferred to the main ED; this was also unlikely to affect our results. It is interesting to note the difference between patient insurance at our main ED from period A to period D. There was a marked overall change in private insurance patients at the main ED from 2006 to 2013, decreasing from 37.7% to 23.8%. However, from period A to period B, we actually saw an increase in privately insured patients at the main ED from 37.7% to 40.8% after the opening of the first FED. This might have been before the effects of the great economic recession, which might have contributed to the decrease that followed in periods C and D. We saw a large drop in privately insured patients from period B to D at FED 1, decreasing from 64.8% to 53.3%. Likewise, there was an increase in self-pay, Medicaid, and Medicare patients from 2006 to 2013. Previous studies have shown a similar trend during this time period showing slight decreases in private insurance and large increases of the amount of patients with Medicaid, Medicare, or simply no insurance (5). This might reflect the financial crisis of 2008, which resulted in changing insurance demographics of patients post recession. It might also reflect the start of the 2010 Affordable Care Act. The difference in payer status between the main ED and FEDs is noteworthy. The location of the FEDs, situated in suburban locations, and the main ED, in the middle of a downtown urban center, should be considered. Many critics believe FEDs treat very few self-pay and Medicaid patients. Our study shows that our FEDs see a large number of patients that are self-pay or Medicaid, ranging from 23% to 32% of FED patients in period D. Our results also show a larger percentage of privately insured patients at our FEDs compared to our main ED. Additionally, the insurance profiles of the main ED in 2006 2007, before any of the FEDs were open and the main ED in 2012 2013 were different with a decrease in private insurance and an increase in the Medicaid, Medicare, and self-pay patients. It is difficult to speculate whether the decrease in private insurance and increase in the uninsured and Medicaid patients at the main ED was due to increased presence of FEDs in the community or the changing economic climate after 2008. Several studies have suggested that the economic recession has caused an increase in the number of uninsured patients due to termination in the workplace and loss of benefits,
469
resulting in an increase in the uninsured seeking medical care at EDs (7). There has also been an increase in patients applying for Medicaid since the recession, up to 70% in some states (7). Our study highlights the increase in self-pay or uninsured patients at the main ED from 2006 to 2013. Previous studies have suggested that the uninsured may present with lower-acuity complaints and may utilize the ED as access for primary care needs (8). Limitations We can only report on trends seen in our data, and this study is subject to bias of a retrospective study, such as missing or inaccurate data. This study was conducted in one hospital system and may not be generalizable to other areas. Patients that visit the ED > 10 times in 1 year could also affect our results. This population represents 0.5% of our total patient population across all four EDs, and our study was not designed to measure their effect on the system. CONCLUSIONS During the three studied time frames (B, C, and D), there were fewer privately insured patients and more self-pay, Medicaid, and Medicare patients at the main ED compared to the FEDs. The number of privately insured patients decreased at both the main ED and FEDs during the study timeframe. The FEDs saw between 23% and 32% self-pay and Medicaid patients. REFERENCES 1. Henneman P, Garb J, Capraro G, et al. Geography and travel distance impact emergency department visits. J Emerg Med 2011;40:333–9. 2. Simon E, Kovacs M, Zhenyu J, et al. A comparison of acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med 2015;33:539–41. 3. Jouriles N, Simon EL, Griffin P, et al. Emergency department wait times are not always accurate. Acad Emerg Med 2013;20:421–3. 4. Simon EL, Griffin P, Jouriles N. The impact of two freestanding emergency departments on a tertiary care center. J Emerg Med 2012;43:1127–31. 5. Downey L, Zun LS, Burke T, et al. Who pays? How reimbursement impacts the emergency department. J Health Hum Serv Adm 2014; 36:400–16. 6. Simon E, Kovacs M, Jia Z, Hayslip D, Orlik K, Jouriles N. A comparison of acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med 2015;33:539–41. 7. Millard WB. Ignoring it isn’t an option: racial bias in emergency medicine. Ann Emerg Med 2009;53:A19–23. 8. Carlson JN, Menegazzi JJ, Callaway CW. Magnitude of national ED visits and resource utilization by the uninsured. Am J Emerg Med 2013;31:722–6.
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ARTICLE SUMMARY 1. Why is this topic important? Freestanding emergency departments (FEDs) are growing rapidly and currently represent 8% to 10% of EDs nationwide. Tertiary care EDs are vital to our ED landscape and their financial viability is important. Evaluating insurance trends at these facilities warrants further study. 2. What does this study attempt to show? This study attempts to show various insurance types of patients that present to three hospital-affiliated freestanding EDs and our main tertiary care ED. 3. What are the key findings? Overall for all time frames studied, private pay is the largest subset of insurance followed by Medicare, Medicaid, and self-pay at the main ED and FEDs. That changed at the main ED in period D, and Medicare became the largest insurance payer. 4. How is patient care impacted? FEDs may increase access to care for patients in the areas they service.