Cost-sharing for
Emergency Care and
Unfavorable Clinical Events:
Findings from the
Safety And Financial Ramifications of
ED Copayments (SAFE) Study
AcademyHealth Annual Conference
7 June 2004
SAFE Study Team
Joseph P. Newhouse, PhD
Maggie Price, MA
Richard Brand, PhD
Tom Ray, MBA
Bruce Fireman, MA
Joseph V. Selby, MD, MPH
John Hsu, MD, MBA, MSCE
Harvard University
Kaiser Foundation Research Institute
University of California, San Francisco
Funding Support:
Agency for Healthcare Research and Quality
No other relevant financial relationships to disclose
Background
•
Health Care Costs Are Increasing Each Year
•
Millions of Americans Face Increasing Levels of
Cost-sharing
•
–
Both Higher Levels and Differential/Tiered Copays
–
A Common Practice Is Higher ED Copays
Clinical Impact of Higher Cost-Sharing for
Emergency Services Is Unclear, Especially in
Managed Care Environment
Cost-Sharing Evidence
•
Important to Establish Outcome Effects
–
No Insurance (Full Cost to Patient) Is Associated With Decreased Use of
Medical Care and Worse Clinical Outcomes
–
RAND HIE Showed ED Cost-sharing (Partial Cost to Patient) Is Associated
With a Reduction in Use of Emergency Care in General Population; No
Apparent Outcome Effect
–
Entire ED Effect Within Lacerations on Non-Sutured Lacerations
•
Comparison with the RAND HIE Results
–
Cost-Sharing the Same for ED and Office Visits
–
Did Not Sample Among Elderly
–
Did Not Study Cost Sharing In Managed Care Settings
–
Small Sample Meant Did Not Establish Effect on Mortality
Objective
To Investigate the
Impact of Cost-sharing for Emergency Care on
Emergency Department (ED) Visits,
Deaths, Hospitalizations, and ICU Admissions
Methods
•
Design: Quasi-experimental Study with Concurrent
Controls (Diff-in-Diff)
•
Natural Experiment: Increase in ED Copayment
Levels for Over Half the Population
•
Population:
–
2,257,445 Patients with Commercial Insurance
–
261,091 Patients with Medicare Insurance
•
Setting: Prepaid, Integrated Delivery System
•
Time Period: 1999 - 2001
•
Excluded: Patients With Medicaid
Cost-Sharing Levels
•
Commercial Insurance:
–
–
–
–
–
•
Free Care: No Cost-sharing for ED care
$1 – 5 Copayments
$10 –15 Copayments
$20 – 35 Copayments
$50+ Copayments
Medicare Insurance:
–
–
–
Free Care: No Cost-sharing for ED care
$1 – 15 Copayments
$20+ Copayments
There were no copayments other than the listed amounts during the study period.
Statistical Analysis
•
Poisson Random Effects Model
•
Propensity Score for Covariates:
Age, Gender, Comorbidity (DxCG-based),
Prior Utilization, SES (2000 US Census- based), Having a
Regular Provider, Pharmacy Copayments, Medical Center
•
Adjusted for Year and Month
Clinical Events
•
ED Visits: In-system and Out-of-system
–
•
All ED Visits
Hospitalizations: In-system and Out-of-system
–
All Non-elective Hospitalizations
–
In-system Hospitalizations with ICU Admissions
•
Deaths: In-system and Out-of-system
–
All-cause Mortality
Results
•
2,257,445 Subjects With Commercial Insurance in 1999
–
–
–
•
61% experienced increased cost-sharing during the study
52% experienced increased cost-sharing in 2000
21% experienced increased cost-sharing in 2001
261,091 Subjects With Medicare Insurance in 1999
–
–
–
•
68% experienced increased cost-sharing during the study
60% experienced increased cost-sharing in 2000
13% experienced increased cost-sharing in 2001
Mean ED Visits:
–
–
•
18.4 Visits Per 100 Person-years (Commercial)
52.0 Visits Per 100 Person-years (Medicare)
Mean Hospitalizations:
–
–
2.4 Hospitalizations Per 100 Person-years (Commercial)
17.9 Hospitalizations Per 100 Person-years (Medicare)
Changes in ED Copayment Levels:
Commercially Insured Subjects (1999-2001)
Commercial Insurance
70
60
Percent of Cohort (%)
ED Copayment Level
50
40
$0
$1 - $5
$10 - $15
$20 - $35
$50 - $100
30
20
10
0
1999
n = 2,257,445
2000
n = 1,989,248
Year
2001
n = 1,817,246
Changes in ED Copayment Levels:
Medicare Insured Subjects (1999-2001)
Medicare Insurance
80
70
ED
Percent of Cohort (%)
60
50
$0
$1 - $15
$20 - $50
40
30
20
10
0
1999
n = 261,091
2000
2001
n = 242,602
n = 228,046
Year
Baseline Characteristics: Commercial
Total
n
(%)
2,257,445
(100)
Age
n
(%)
Asthma
211,684
(9.4)
Diabetes
69,065
(3.1)
Heart Failure
6,936
(0.3)
Coronary Artery Disease
25,194
(1.1)
177,524
(7.9)
1,947,136
(86.3)
555,516
(24.6)
2,222,704
(98.5)
$0-$5 Copayments
1,536,891
(68.1)
$7-$15 Copayments
556,085
(24.6)
Co-insurance
164,469
(7.3)
Chronic Disease Status in
1998
<15yrs
480,188
(21.3)
15-17yrs
111,607
(4.9)
18-29yrs
375,413
(16.6)
30-39yrs
394,481
(17.5)
Hypertension
40-49yrs
413,975
(18.3)
ED Visits in 1998
50-64yrs
433,680
(19.2)
65-74yrs
36,106
(1.6)
75-84yrs
10,022
(0.4)
85+yrs
1,973
(0.1)
1,146,478
(50.8)
508,861
(22.5)
Female
Low SES
Neighborhood
No Visits
Office Visits in 1998
No Visits
Hospitalizations in 1998
No Hospitalizations
Drug Cost-sharing
Baseline Characteristics: Medicare
Total
n
(%)
261,091
(100)
Age
n
(%)
Asthma
24,646
(9.4)
Chronic Disease Status in 1998
<15yrs
26
(0)
Diabetes
35,750
(13.7)
15-17yrs
0
(0)
Heart Failure
14,380
(5.5)
18-29yrs
298
(0.1)
Coronary Artery Disease
36,600
(14)
30-39yrs
1,309
(0.5)
Hypertension
118,204
(45.3)
40-49yrs
2,646
(1)
ED Visits in 1998
50-64yrs
9,924
(3.8)
194,327
(74.4)
65-74yrs
142,447
(54.6)
75-84yrs
85,074
(32.6)
22,146
(8.5)
85+yrs
19,367
(7.4)
Female
145,810
(55.8)
237,142
(90.8)
Low SES
Neighborhood
49,251
(18.9)
$0-$5 Copayments
119,672
(45.8)
$7-$15 Copayments
130,166
(49.9)
Co-insurance
11,253
(4.3)
No Visits
Office Visits in 1998
No Visits
Hospitalizations in 1998
No Hospitalizations
Drug Cost-sharing
Unadjusted Rates of Clinical Events by ED Copayment Level
Across All Years (1999-2001)
Commercial Insurance Population
ED
Copa ym ent
Leve l
Mea n
Office
Copa ym ent
Person years
ED Visits
Hospitalizations
D eaths
$0
$0
1,077,940
Visits Ra te*
219,349 20.35
$1-5
$5
1,102,233
216,740 19.66
26,445 2.40
6,914 0.63
2,236 0.20
$10-15
$12
600,072
110,254 18.37
10,852 1.81
2,392 0.40
640 0.11
$20-35
$8
2,490,448
441,951 17.75
64,556 2.59
17,454 0.70
5,453 0.22
$50-100
$11
377,448
53,425 14.15
7,248 1.92
1,969 0.52
531 0.14
135,520 2.40
36,060 0.64
10,800 0.19
To tal
5,648,142
1,041,719
18.44
Adm it s Ra te*
26,419 2.45
ICU
Admi ssions
Adm its Ra te* Counts Ra te*
7,331 0.68
1,940 0.18
*Rates re po rted as events per 100 person-years. Pa tients wi th time -va ryi ng ED cop aym en ts
contribut e per son-time to mu ltiple cop aym en t-levels.
Unadjusted Rates of Clinical Events by ED Copayment Level
Across All Years (1999-2001)
Medicare Insurance Population
ED
Copayme nt
Level
Mean Office
Copayme nt
Personyears
ED Visits
Hospit alizations
Deaths
$0
$0
140,558
Visits Rate*
74,367 52.91
$1-15
$4
241,198
125,599 52.07
41,742 17.31
13,670 5.67
8,287 3.44
$20-50
$9
324,614
167,641 51.64
58,829 18.12
19,075 5.88
12,527 3.86
706,369
367,607 52.04
126,166 17.86
40,965 5.80
25,839 3.66
Tot al
Ad m its Rate*
25,595 18.21
ICU
Ad missi ons
Ad mits Rate* Cou nt s Rate*
8,220 5.85
5,025 3.58
*Rates reported as events per 100 person-years. Patients with time-varying ED copayments
contribute person-time to multiple copayment-levels.
Adjusted Relative Rates of Clinical Events by
ED Copayment Level:
Commercial Insurance Population
ED
Copa ym ent
Leve l
$0
ED Visits
RR (95% CI)
1.0
Hospitalizations
RR (95% CI)
1.0
ICU Admi ssions
RR (95% CI)
1.0
D eaths
RR (95% CI)
1.0
$1-5
0.962
(0.955 , 0.970)
0.999
(0.978 , 1.020)
1.010
(0.972 , 1.050)
1.086
(1.021 , 1.156)
$10-15
0.932
(0.922 , 0.941)
0.932
(0.905 , 0.960)
0.895
(0.845 , 0.947)
0.909
(0.822 , 1.006)
$20-35
0.879
(0.873 , 0.886)
0.961
(0.943 , 0.980)
0.954
(0.922 , 0.988)
0.857
(0.810 , 0.907)
$50-100
0.765
(0.756 , 0.774)
0.902
(0.873 , 0.932)
0.946
(0.891 , 1.004)
0.903
(0.818 , 0.998)
Adjusted Relative Rates of Clinical Events by
ED Copayment Level:
Medicare Insurance Population
ED
Copa ym ent
Leve l
$0
ED Visits
RR (95% CI)
1.0
Hospitalizations
RR (95% CI)
1.0
ICU Admi ssions
RR (95% CI)
1.0
D eaths
RR (95% CI)
1.0
$1-15
0.973
(0.956 , 0.989)
0.987
(0.962 , 1.013)
0.990
(0.949 , 1.031)
1.007
(0.966 , 1.050)
$20-50
0.956
(0.939 , 0.973)
0.994
(0.967 , 1.022)
1.003
(0.959 , 1.049)
0.873
(0.834 , 0.913)
Adjusted Relative Rates of Clinical Events by ED Copayment
Level in Subjects Living in Low SES Neighborhoods*:
Commercial Insurance Population
ED
Copa ym ent
Leve l
$0
ED Visit
RR (95% CI)
1.0
Hospitalization
RR (95% CI)
1.0
ICU Admi ssion
RR (95% CI)
1.0
Deaths
RR (95% CI)
1.0
$1-5
0.930
(0.916 , 0.944)
0.955
(0.915 , 0.996)
0.971
(0.898 , 1.050)
1.057
(0.932 , 1.199)
$10-15
0.909
(0.891 , 0.928)
0.919
(0.866 , 0.976)
0.876
(0.779 , 0.985)
0.996
(0.810 , 1.226)
$20-35
0.847
(0.835 , 0.859)
0.947
(0.911 , 0.984)
0.931
(0.866 , 1.000)
0.922
(0.823 , 1.033)
$50-100
0.737
(0.719 , 0.756)
0.842
(0.787 , 0.900)
0.826
(0.727 , 0.938)
1.084
(0.885 , 1.327)
* We defined low SES neighborhoods as areas with low income (≥20% of residents have
household incomes below the federal poverty level) or low educational attainment (≥25% of
residents ≥25 years old have less than a high-school education).
Adjusted Relative Rates of Clinical Events by ED Copayment
Level in Subjects Living in Low SES Neighborhoods*:
Medicare Insurance Population
ED
Copa ym ent
Leve l
$0
ED Visit
RR (95% CI)
1.0
Hospitalization
RR (95% CI)
1.0
ICU Admi ssion
RR (95% CI)
1.0
Deaths
RR (95% CI)
1.0
$1-15
0.924
(0.889 , 0.961)
0.953
(0.897 , 1.013)
0.959
(0.872 , 1.055)
0.894
(0.814 , 0.983)
$20-50
0.929
(0.893 , 0.967)
0.961
(0.904 , 1.022)
0.942
(0.852 , 1.041)
0.846
(0.765 , 0.937)
* We defined low SES neighborhoods as areas with low income (≥20% of residents have
household incomes below the federal poverty level) or low educational attainment (≥25% of
residents ≥25 years old have less than a high-school education).
Conclusions
In This Population of Patients in a Prepaid, Integrated
Delivery System:
•
Having to Pay a Portion of ED Costs Reduced ED
visits, and by Roughly the Same Amount as in the
RAND HIE
•
There was No Evidence of Clinical Harm Associated
with Having to Pay Higher ED Costs, i.e. Higher
Cost-Sharing Did Not Result in More
Hospitalizations or Deaths.
Limitations
•
Range of ED Cost-sharing Levels: Free Care to $100
Copayments Per Visit
–
•
No Measures of Patient Awareness
–
•
But Copays Above $100 per Visit Are Rare
May Have Understated Steady State Effects
Single Integrated Delivery System
Implications
•
Moderate Levels of Cost-Sharing for
Emergency Services Appear Save Money With
No Evidence of Adverse Effects