Improving Care for the
Uninsured by Providing Links
to Primary Care
Susan H. Busch, Ph.D. 1
Sarah McCue Horwitz, Ph.D. 2
Kathleen M. B. Balestracci, Ph.D. 1
Jim Rawlings, M.P.H. 1
1 Health Policy & Administration, Yale University, and
2 Department of Psychiatry, Case Western Reserve Medical School
1
Background
• The New Haven Wellness Information
Network (WIN) was designed to improve
access to care for uninsured patients
utilizing the Yale New Haven Hospital
Emergency Department.
• Provided case management services to
link patients to primary care medical
homes.
2
Background
• Emergency Departments (EDs) have seen
enormous increases in visits, with more than
one-half considered non-urgent.
• Although much of this increase is by insured
patients, EDs are a major provider of care for
the uninsured.
• ED care, compared to primary care is
expensive, fragmented and lacking in basic
preventive services.
3
Results
Linkages led to:
• More primary care visits,
• Fewer hospitalizations,
• No change in ED use…
• Although ED visits became ‘less intense,’
• Approximately break-even for the
hospital.
4
Methods
Design: Randomized Clinical Trial
Shifts were randomly assigned to intervention
or comparison.
Timeframe: Recruitment for the evaluation took
place between April 22, 2002 and July 21,
2002.
Sample Size: 231 individuals
• 121 intervention,
• 110 comparisons.
5
ED Referral/Case Management
Intervention
On intervention shifts, patients who were uninsured,
living in New Haven and without a primary health
care provider were approached.
• Healthcare site chosen,
• Patient information faxed to the selected care site,
• Case Managers at the Primary Care Sites
contacted participants and made appointments for
case management assessments and/or medical
care.
6
Analytic Design
• Consider all inpatient and ED visits
within a six month-window after the
initial ED visit.
• We omit data from the initial ED visit.
• In sensitivity analysis omit all care related
to initial ED visit.
7
Economic Evaluation
Provide evidence for sustainability from
multiple perspectives:
• Hospital,
• Health Care System (including FQHCs),
• Societal.
8
Data
• Utilization data was provided by the primary
care clinics and both New Haven hospitals
• Inpatient and outpatient costs assigned by a
standardized, computerized, comprehensive
cost assignment system including:
•
•
•
•
•
Personnel,
Laboratory,
Specialty services,
Room and board, and
Other direct and indirect costs.
9
Results: Demographics for
WIN Evaluation Participants
Intervention
Comparison
82 (66.7%)
85 (77.3%)
39 (32.2%)
28 (22.7%)
62 (51.2%)
55 (50.0%)
31-50 years
45 (37.2%)
49 (44.6%)
> 50 years
14 (11.6%)
6 (5.5%)
Race: White, not Hispanic
26 (22.6%)
21 (19.8%)
Black, not Hispanic
43 (37.4%)
45 (42.5%)
Hispanic (White or Black)1
46 (40.2%)
40 (37.7%)
Marital Status: Single
83 (69.5%)
77 (71.3%)
Married
22 (18.6%)
19 (17.6%)
Other5
14 (11.9%)
12 (11.1%)
Sex: Male
Female
Age: < 30 years
X2
2.60 (p=0.11)
3.27 (p=0.19)
0.63 (p=0.72)
0.24 (p=0.95)
10
Results: Reasons for ED Visits
No place to go
175 (76.1%)
Knew ED would be open
149 (64.8%)
Would be seen without appointment
139 (60.4%)
No insurance
121 (52.6%)
ED would give best care for problem
112 (48.7%)
No transportation elsewhere
3 (1.3%)
Refused care elsewhere
0 (0.0%)
11
Results: Utilization Outcomes
Intervention
Comparison
p-value
Case management and/or
Medical Visit
51 %
(62/121)
15 %
(16/110)
34.7 (p<.01)
Inpatient admissions
0.8 %
(1/121)
5.5 %
(6/110)
4.2 (p=.04)
ED visits
37 %
(45/121)
33 %
(36/110)
.50 (p=.48)
12
Cost per ED visit
Intervention Comparison
Pre - period
Post - period
$330
$245
$330
$312**
Hypothesize differences are due to less intensity in ED visits for
Intervention patients.
13
Hospital Costs (per Person)
Intervention
ED costs
$60
Inpatient costs
$6
Comparison
$57
$183**
14
Case Management Costs
•
•
•
•
•
2 months on project
3 case managers
Annual salary + fringe = $ 57,375 /year
123 Intervention patients
Cost of $233 per intervention patient
15
Results
• Benefits:
• $173 reduction in net hospital costs (per
enrollee).
• Costs:
• $233 per person for case management
(per enrollee).
16
Limitations
• Small data set
• Limited to one Northeastern urban location
• Questions about generalizability
17
Future Analyses
• Health related outcomes:
• Treatment for diabetes, hypertension,
depression,
• Preventive care (e.g., advice on smoking,
obesity).
• Societal perspective:
• Include costs of primary care visits,
• Include labor market outcomes,
• Include “quality of life” benefits.
18
Conclusion
• ED Referral/Case Management intervention
can establish medical homes for uninsured
individuals.
• Intervention is associated with lower hospital
use.
• Although not cost saving, intervention clearly
reduces hospital health care costs.
• Additional costs may be justified by
improvements in health and productivity.
19