Better primary care needed to reduce unnecessary ED visits by Medicaid patients

Although a goal of Medicaid expansion under the Affordable Care Act was to provide Medicaid patients with a source of nonemergency care outside of hospital emergency departments (EDs), researchers suggest that these newly enrolled patients will likely continue to look to EDs for treatment of chronic diseases and other nonemergency issues, despite state attempts to impose fees on ED visits. Health policy researchers at the Perelman School of Medicine at the University of Pennsylvania, the Johns Hopkins Bloomberg School of Public Health, and the Institute of Health Policy Studies at the University of California, San Francisco, suggest in a new Perspective published in the New England Journal of Medicine that patient-centered medical homes may be more effective in reducing the number of Medicare patients seeking nonemergency care in EDs than increasing the cost of the visits.

"Instead of requiring Medicaid patients to pay for a portion of their ED care, some states are trying to provide them with better alternatives to the ED," writes lead author Ari B. Friedman, MS, a fellow in Penn's Leonard Davis Institute of Health Economics, and his coauthors. "At the core of the alternative approach to reducing ED visits are key components of the patient-centered medical home model, including care coordination, case management, extended hours and walk-in visits."

The authors point out that the eight states that have implemented copayments for nonemergency ED visits saw no reduction in ED visits by Medicaid patients relative to states that did not implement such copayments. On the other hand, preliminary studies have found that medical home initiatives — where patients have access to a primary care provider who can help prevent exacerbations of chronic illnesses that might otherwise lead to acute crisis — are effective in reducing ED use among Medicaid patients.

Some of the issues that need to be addressed for the patient-centered medical home approach to succeed include growing community health centers, establishing policies that increase physician participation in Medicaid, and providing better support for practices, including after-hours coverage. The authors also point out that transportation access is a problem, and that new policies to encourage the use of primary care should consider providing patients with taxi vouchers, subway tokens, or paratransit access.

The authors conclude by saying that "the Obama administration's decision to approve demonstration projects involving high cost sharing and loss of transportation coverage is concerning. Instead, CMS [the Centers for Medicare and Medicaid Services] might encourage state initiatives to develop robust ED alternatives… to improve the care of all medically or financially vulnerable Americans."