December 12, 2017

No, the uninsured don't use the ED more than the insured, study finds

Daily Briefing

    Contrary to a widespread belief, uninsured adults are no more likely to use the ED than insured adults, according to a study published in Health Affairs—but the study also offered a potential explanation for how the belief arose in the first place.

    Primer: Right-Size ED utilization for acute behavioral health patients

    Study details

    For the study, researchers analyzed data on insured and uninsured adults ages 19 to 64 from the 2013 Medical Expenditure Panel Survey. They also looked at data from the 2013 National Hospital Ambulatory Medical Care Survey.

    The researchers found that uninsured adults use the ED about as frequently as do insured patients. Specifically, the researchers found that about 12.2% of uninsured patients visited the ED in 2013, compared with about 11.1% of privately insured patients and 29.3% of Medicaid beneficiaries.

    Overall, the researchers found that about 13.7% of patients who had either private or public insurance coverage used the ED in 2013.

    However, the researchers found a stark difference in usage rates for outpatient care: About 77% of adults with private insurance and 75% of adults with Medicaid used outpatient services in 2013, compared with 42% of uninsured adults.

    Why does it seem like more uninsured patients use the ED?

    The researchers said that while their study appeared to bust the myth that uninsured adults use the ED more frequently than insured adults, it also suggested an explanation for how the false belief arose in the first place: Uninsured patients "are most likely encountered in the ED," as such patients are relatively unlikely to use outpatient services.

    The authors explained that, while the Emergency Medical Treatment and Labor Act gives the uninsured the right to be treated in the ED, they can legally be denied care in outpatient settings. Further, they wrote that low-income populations who lack health insurance may face stigma, challenges developing relationships with providers, or confusion about coverage benefits—all of which may discourage such individuals from seeking outpatient care.

    Further, John Graves, an assistant professor of health policy at the Vanderbilt School of Medicine, said in a tweet that while he "really like[d] this study," there was one limitation to consider: "the use of payer to determine insurance status."

    Graves explained that a patient who currently lacks health insurance may seek out care at an ED, at which point the hospital "determines they may be eligible for Medicaid and enrolls them presumptively." As a result, the payer "ultimately is Medicaid," so the patient would not show up as uninsured in the researchers' data.

    That effect "would reconcile the anecdote/myth [that the uninsured overuse the ED] with these data," Graves added (Knowles, Becker's Hospital Review, 12/7; Scott, Vox, 12/5; Graves tweet, 12/5).

    Next, get the primer for reducing avoidable ED utilization

    Are specific patient populations making up a significant proportion of your ED visits? Each installment in our Right-Sizing ED Use primer series takes a lens to one of these frequent user subgroups.

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