Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland2currently with the White House Social and Behavioral Sciences Team, Washington, DC.
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
JAMA Intern Med. 2015 Mar;175(3):393-8. doi: 10.1001/jamainternmed.2014.7582.
High unemployment during the 2007-2009 Great Recession and eligibility expansions have increased the size and cost of Medicaid. To provide states with flexibility in administering the program while containing costs, the Deficit Reduction Act of 2005 (DRA) gave states the authority to impose cost-sharing strategies, including emergency department (ED) copayments for nonurgent visits. To our knowledge, there has been no previous longitudinal analysis of the effect of the DRA on health care utilization outcomes for Medicaid beneficiaries.
To evaluate the effect of the DRA, which allowed states to enforce ED copayments for nonurgent visits, on ED utilization among Medicaid beneficiaries and to compare the effect among beneficiaries living in states that did and did not adopt ED copayments.
DESIGN, SETTING, AND PARTICIPANTS: A difference-in-difference quasi-experimental approach was used to compare trends in ED use among Medicaid beneficiaries from January 2001 to December 2010. Eight states with ED copayments for nonurgent ED visits (copayment states) were compared with 10 states with zero ED copayments (control states). The study cohort was the population of individuals 19 to 64 years old enrolled in Medicaid for a full calendar year as collected by the Medical Expenditure Panel Survey, a nationally representative survey of noninstitutionalized US civilians. The cohort consisted of 3122 adult Medicaid recipients in copayment states and 7433 adult Medicaid recipients in control states.
The main exposure was the copayment enforcement authority of the DRA. The study controlled for sex, age, race, marital status, income relative to the federal poverty level, educational level, and self-reported health status.
The primary outcome of this study was the change in the rate of ED utilization following the DRA. Additional outcomes included changes in the rate of outpatient medical provider visits and inpatient length of stay. Visits were not coded according to urgency, which prevented us from examining only nonurgent ED use.
Estimates from a zero-inflated Poisson regression model detected no statistically significant change in annual ED admissions per Medicaid enrollee (change, 0.05; 95% CI, -0.05 to 0.16) in copayment states compared with control states following the DRA. There was also no change in the rate of outpatient medical provider visits (change, 0.02; 95% CI, -0.31 to 0.35) or in annual inpatient days (change, 0.13; 95% CI, -0.31 to 0.57) per Medicaid enrollee.
Granting states permission to collect copayments for nonurgent visits under the DRA did not significantly change ED or outpatient medical provider use among Medicaid beneficiaries.
2007-2009 年大衰退期间的高失业率和资格扩大增加了医疗补助计划的规模和成本。为了在控制成本的同时为各州提供管理该计划的灵活性，2005 年《减赤法案》（DRA）赋予各州实施成本分担策略的权力，包括对非紧急就诊收取急诊部门（ED）共同支付费用。据我们所知，此前尚无关于 DRA 对医疗补助受益人的医疗保健利用结果影响的纵向分析。
评估 DRA 的效果，该法案允许各州对非紧急 ED 就诊收取 ED 共同支付费用，以评估其对医疗补助受益人的 ED 利用的影响，并比较在实施和未实施 ED 共同支付费用的州中受益人的效果。
设计、设置和参与者：采用差异中的差异准实验方法，比较 2001 年 1 月至 2010 年 12 月期间医疗补助受益人的 ED 使用趋势。将 8 个对非紧急 ED 就诊收取 ED 共同支付费用的州（共同支付州）与 10 个没有 ED 共同支付费用的州（对照州）进行比较。研究队列是由医疗支出面板调查收集的在整个日历年内完全参加医疗补助计划的 19 至 64 岁人群，这是一项针对非机构化美国平民的全国代表性调查。该队列包括共同支付州的 3122 名成年医疗补助受助人，以及对照州的 7433 名成年医疗补助受助人。
主要暴露因素是 DRA 的共同支付执行权。研究控制了性别、年龄、种族、婚姻状况、收入与联邦贫困水平的相对关系、教育水平和自我报告的健康状况。
本研究的主要结果是在 DRA 之后，ED 利用率的变化。其他结果包括门诊医疗服务提供者就诊率和住院时间的变化。就诊没有根据紧急程度进行编码，这使我们无法仅检查非紧急 ED 的使用情况。
零膨胀泊松回归模型的估计结果显示，与对照州相比，共同支付州在 DRA 之后，每位医疗补助参保人每年的急诊就诊率（变化量 0.05；95%CI，-0.05 至 0.16）没有统计学意义上的显著变化。门诊医疗服务提供者就诊率（变化量 0.02；95%CI，-0.31 至 0.35）或每位医疗补助参保人每年的住院天数（变化量 0.13；95%CI，-0.31 至 0.57）也没有变化。
根据 DRA 向各州授予收取非紧急就诊共同支付费用的许可，并未显著改变医疗补助受益人的 ED 或门诊医疗服务提供者的使用情况。
