SAFE Study Team
Cost-sharing for
Emergency Care and
Unfavorable Clinical Events:
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
Findings from the
Safety And Financial Ramifications of
ED Copayments (SAFE) Study
Harvard University
Kaiser Foundation Research Institute
University of California, San Francisco
AcademyHealth Annual Conference
7 June 2004
Funding Support:
Agency for Healthcare Research and Quality
No other relevant financial relationships to disclose
Background
•
•
•
Health Care Costs Are Increasing Each Year
Cost-Sharing Evidence
•
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
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
Methods
Objective
To Investigate the
Impact of Cost- sharing for Emergency Care on
Emergency Department (ED) Visits,
Deaths, Hospitalizations, and ICU Admissions
•
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
1
Cost-Sharing Levels
•
–
–
–
–
–
•
Statistical Analysis
Commercial Insurance:
Free Care: No Cost-sharing for ED care
$1 – 5 Copayments
$10 –15 Copayments
$20 – 35 Copayments
$50+ Copayments
•
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
Medicare Insurance:
–
–
–
Free Care: No Cost-sharing for ED care
$1 – 15 Copayments
$20+ Copayments
•
Adjusted for Year and Month
There were no copayments other than the listed amounts during the study period.
Results
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
•
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:
–
–
Changes in ED Copayment Levels:
Commercially Insured Subjects (1999-2001)
2.4 Hospitalizations Per 100 Person-years (Commercial)
17.9 Hospitalizations Per 100 Person-years (Medicare)
Changes in ED Copayment Levels:
Medicare Insured Subjects (1999-2001)
Medicare Insurance
80
Commercial Insurance
70
261,091 Subjects With Medicare Insurance in 1999
•
All-cause Mortality
61% experienced increased cost-sharing during the study
52% experienced increased cost-sharing in 2000
21% experienced increased cost-sharing in 2001
–
–
–
Deaths: In- system and Out- of-system
–
2,257,445 Subjects With Commercial Insurance in 1999
–
–
–
70
ED
60
60
ED Copayment Level
50
50
40
$0
$1 - $15
$20 - $50
40
$0
$1 - $5
$10 - $15
$20 - $35
$50 - $100
30
20
30
20
10
10
0
1999
0
1999
n = 2,257,445
2000
n = 1,989,248
2001
n = 1,817,246
n = 261,091
2000
n = 242,602
2001
n = 228,046
Year
Yea r
2
Baseline Characteristics: Commercial
Total
n
(%)
2,257,445
(100)
Age
<15yrs
480,188
(21.3)
15-17yrs
111,607
(4.9)
18-29yrs
375,413
(16.6)
30-39yrs
394,481
(17.5)
40-49yrs
413,975
(18.3)
50-64yrs
433,680
(19.2)
65-74yrs
36,106
(1.6)
75-84yrs
10,022
(0.4)
85+yrs
Female
Low SES
Neighborhood
1,973
(0.1)
1,146,478
(50.8)
508,861
(22.5)
Baseline Characteristics: Medicare
n
(%)
Asthma
211,684
(9.4)
Chronic Disease Status in
1998
n
(%)
261,091
(100)
<15yrs
26
(0)
Asthma
24,646
(9.4)
15-17yrs
0
(0)
Diabetes
35,750
(13.7)
14,380
(5.5)
Total
Diabetes
69,065
(3.1)
Heart Failure
6,936
(0.3)
Coronary Artery Disease
25,194
(1.1)
Hypertension
177,524
(7.9)
Age
ED Visits in 1998
No Visits
1,947,136
(86.3)
Office Visits in 1998
No Visits
555,516
(24.6)
18-29yrs
298
(0.1)
30-39yrs
1,309
(0.5)
Coronary Artery Disease
36,600
(14)
40-49yrs
2,646
(1)
Hypertension
118,204
(45.3)
ED Visits in 1998
194,327
(74.4)
50-64yrs
9,924
(3.8)
65-74yrs
142,447
(54.6)
75-84yrs
85,074
(32.6)
Female
No Hospitalizations
2,222,704
Low SES
Neighborhood
(98.5)
Drug Cost-sharing
$0
Mean
Office
Copayment
$0
$1-5
$5
$10-15
$12
$20-35
$50-100
$8
$11
Personyears
1,077,940
$0
49,251
(18.9)
22,146
(8.5)
237,142
(90.8)
Drug Cost-sharing
$0-$5 Copayments
119,672
(45.8)
(68.1)
$7-$15 Copayments
130,166
(49.9)
(24.6)
Co-insurance
11,253
(4.3)
Co-insurance
164,469
(7.3)
ED Visits
Visits Rate*
219,349 20.35
Hospitali zatio ns
Adm its Rate*
26,419 2.45
ICU
Admiss ions
26,445 2.40
6,914 0.63
2,236 0.20
600,072
110,254 18.37
10,852 1.81
2,392 0.40
640 0.11
441,951 17.75
64,556 2.59
17,454 0.70
Unadjusted Rates of Clinical Events by ED Copayment Level
Across All Years (1999-2001)
Medicare Insurance Population
Deaths
Adm its Rate* Counts Rate*
7,331 0.68
1,940 0.18
ED
Copayment
Level
Mean Office
Copayment
Personyears
140,558
ED Visits
Visits Rate*
74,367 52.91
Hospitalizations
Admits Rate*
25,595 18.21
ICU
Admissions
53,425 14.15
7,248 1.92
1,969 0.52
531 0.14
5,648,142 1,041,719 18.44
135,520 2.40
36,060 0.64
10,800 0.19
$0
$0
$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
*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:
Adjusted Relative Rates of Clinical Events by
ED Copayment Level:
Commercial Insurance Population
Medicare Insurance Population
ED Visits
RR (95% CI)
1.0
Hospitalizations
RR (95% CI)
1.0
ICU Admissions
RR (95% CI)
1.0
Deaths
Admits Rate* Counts Rate*
8,220 5.85
5,025 3.58
5,453 0.22
*Rat es re po rted as events per 100 person -years. Pa tients wi th time -va ryi ng ED cop aym en ts
contribut e person -time to mu ltiple cop aym en t-levels.
ED
Copayment
Level
No Hospitalizations
556,085
216,740 19.66
377,448
No Visits
Hospitalizations in 1998
1,536,891
Total
Total
(7.4)
(55.8)
$0-$5 Copayments
1,102,233
2,490,448
19,367
145,810
No Visits
Office Visits in 1998
$7-$15 Copayments
Unadjusted Rates of Clinical Events by ED Copayment Level
Across All Years (1999-2001)
Commercial Insurance Population
ED
Copayment
Leve l
(%)
Heart Failure
85+yrs
Hospitalizations in 1998
n
Chronic Disease Status in
1998
Deaths
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)
ED
Copayment
Level
$0
ED Visits
RR (95% CI)
1.0
Hospitalizations
RR (95% CI)
1.0
ICU Admissions
RR (95% CI)
1.0
Deaths
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)
3
Adjusted Relative Rates of Clinical Events by ED Copayment
Level in Subjects Living in Low SES Neighborhoods*:
Commercial Insurance Population
ED
Copayment
Level
$0
ED Visit
RR (95% CI)
1.0
Hospitalization
RR (95% CI)
1.0
ICU Admission
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
Copayment
Level
$0
•
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.
Hospitalization
RR (95% CI)
1.0
ICU Admission
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:
ED Visit
RR (95% CI)
1.0
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
4