The Effects
Th
Eff t off Emergency
E
Department Copayments on
Medicaid Enrollees’ Use of Physician
and Hospital Services
AcademyHealth 2010
Karoline Mortensen,
Mortensen University of Maryland
Paula H. Song, The Ohio State University
Hanns Kuttner,
Kuttner Hudson Institute
Introduction
• Do we really
ll know
k
who
h is
i showing
h i up in
i the
h
emergency department (ED) (Newton et al.
2009).
2009)
• Medicaid enrollees are disproportionately more
likely than those with other types of insurance to
have an emergency department visit (Mortensen
and
d Song
S
2008,
2008 Cunningham
C
i h
2006,
2006 Pitts
Pi et al.l
2006).
• Incentives to “re‐direct” enrollees to “more
appropriate” sources of care
Cost Sharing in Medicaid
• States increasingly implementing copayments
for non‐emergent emergency department
(ED) visits
– Physician and inpatient copayments remain
relatively
l i l constant
• States with higher
g
rates of ED use more likelyy
to implement ED cost sharing
• Very few studies on the effects of ambulatory
and ED copayments in Medicaid
Cost sharing in Medicaid
• Federal law prohibits Medicaid from charging
cost sharing for:
– Children
– Pregnant women (for services related to the
p g
pregnancy)
y)
– Institutionalized individuals
– Emergency
g y services
• Administrative costs may be high
– Track amount paid for 5% income max
– Copayment can only be collected after the service
– Who determines if it is an emergency?
What is an Emergency?
• Conditions with symptoms of such severity
that,, without care,,
– The person’s health would be in serious jeopardy,
– Or he would risk serious impairment to bodily
functions,
– Or
O serious
i
d
dysfunction
f ti off any organ or body
b d part.
t
Research Question
• Do copayments for non‐emergent ED visits
affect p
physician
y
visits or inpatient
p
utilizations
for Medicaid enrollees?
Data
•
•
•
•
Medical Expenditure
p
Panel Surveyy ((MEPS))
Nationally representative household survey
2001 to 2006 Household Component data
Top 29 most populous states
– 89% of MEPS survey respondents are in the 29
most populous states
• Adults age 19 to 64
– Enrolled in Medicaid for 12 months or more
• Data on state Medicaid copayments and policy
change dates
Methods
• Difference
Difference‐in‐Differences
in Differences Analysis
• Linear Probability Model
• Model includes state‐level fixed effects,
year controls, and personal
characteristics
Dates of Change and Copayment Amounts
Visit Analysis
y
• 87,324
,
p
person‐months of Medicaid
enrollees
• Dependent variable is binary indicator of:
–Physician Visit in month
–Inpatient
p
stayy in month
Characteristics of Enrollees in Change
Versus Non‐Change States
Ch
Characteristic
i i
Ch
Change
State
S
(%)
Non‐Change
Ch
State
S
(%)
Physician Visits (% with 1+, monthly)
38.8
32.8*
Inpatient Stay (% with 1+
1+, monthly)
23
2.3
1 8*
1.8
ED Visits (prob. of 1+, monthly)
4.1
3.1*
White
61.2
39.9*
Black
27.0
26.6
6.0
24.8*
Less than 100% FPL
59 0
59.0
52 4*
52.4
100‐200% FPL
25.7
30.9*
200‐400% FPL
12.3
13.6
Above 400 FPL
3.0
3.1
Race
Hispanic
Income
* p < .05
Results
• Difference‐in‐Differences results suggest ED
copayments had no effect on physician or
inpatient utilization
• 0.014
0 014 percentage point
i decrease
d
in
i Medicaid
M di id
enrollees reporting physician visits in change
states after the copayment changes
– Statistically insignificant (s.e. 0.019)
• 0
0.0007
0007 percentage point increase in inpatient
hospitalizations
– Statistically insignificant (s.e. 0.0036)
• No effects on physician visits of privately insured
or uninsured
Conclusions
• Analysis of average effects of non‐emergent
cost sharingg on national data suggest
gg
– Copayments had no effect on Medicaid enrollees’
use of physician services
– Copayments had no effect on increased
probability of an inpatient stay
Policy Implications
• Deficit Reduction Act 2005 allows states
significant flexibility in implementing and
increasing cost sharing in Medicaid
• PPACA of 2010 eliminates cost sharing for
many preventive and screening services‐ an
unintended consequence could be that states
increase cost sharing for non‐emergent ED
visits
ii
– Maybe higher copayments have an effect?