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Affordable Care Act May Reduce ER Visits But Doesn’t Affect Hospitalizations

Two studies find only modest changes

Two patient groups created by the Patient Protection and Affordable Care Act (PPACA) –– Medicare patients enrolled in federally designated patient-centered medical homes and people under 26 years of age who are allowed to remain on their parents’ health insurance –– had slightly fewer emergency department (ED) visits than they had before health-care reform. However, there was no change in the rate of the most expensive types of emergency visits –– those that lead to hospitalization, according to the American College of Emergency Physicians.

A study published in the Annals of Emergency Medicine examined the rate of ED visits and hospitalizations for Medicare patients treated by patient-centered medical homes. (Primary care practices can receive a special designation as patient-centered medical homes [PCMHs] from the National Committee for Quality Assurance.) From 2008 to 2010, outpatient ED visits grew more slowly for Medicare patients being treated by PCMH practices than by non-PCMH practices. The rate of growth per 100 PCMH beneficiaries was 13 fewer visits for 2009 and 12 fewer visits for 2010. There was no effect on the rates of inpatient hospitalization.

“The concept of ‘medical homes’ has been around since the 1960s, and reviews of their effectiveness in improving health outcomes have been mixed,” said lead author Jesse Pines, MD, MBA, FACEP. “Our study shows that these models can have a positive effect on patients, as far as limiting outpatient emergency department use, but they don’t seem to keep patients from being hospitalized, which is many times more expensive than ER visits. Further evaluation of medical homes is needed, particularly on patients who are most likely to benefit, such as those with multiple health problems, a compromised social situation, or both.”

Maria Raven, MD, MPH, FACEP, of the University of California, San Francisco, who wrote a companion editorial, cautions that “health care delivery is rarely simple, and studying health care utilization is quite complex. The type of outpatient emergency department use that may be affected by PCMH practices is not a main driver of health care expenditures when compared to inpatient hospital admissions and skilled nursing care.”

In a related study, also published in the Annals of Emergency Medicine, the ED visit rate declined by 1.6 per 1,000 people among young adults (19 to 25 years of age) covered by their parents’ private insurance plans. The decrease was concentrated among women, weekday visits, nonemergency conditions, and conditions that could be treated outside the ED.

“The reductions in ER use among young people were quite specific to less-severe conditions that could be handled in a primary care setting, which is not unexpected,” said lead author Yaa Akosa Antwi, PhD. “Overall, the reductions in ER use were modest, which suggests that even when the [PP]ACA is fully implemented, population-level changes in emergency department use may also be modest. Future research will be needed to assess the effect of coverage expansions on the broader range of adults who will gain coverage under the [PP]ACA in the next several years."

Sources: ACEP; March 12, 2015; AEM (Pines); March 10, 2015; and AEM (Antwi); March 10, 2015.

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