Pimentel Laura, Anderson David, Golden Bruce, Wasil Edward, Barrueto Fermin, Hirshon Jon M
University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland.
Baruch College, Zicklin School of Business, Operations Management, City University of New York, New York, New York.
West J Emerg Med. 2017 Apr;18(3):356-365. doi: 10.5811/westjem.2017.1.31778. Epub 2017 Mar 13.
On January 1, 2014, the financing and delivery of healthcare in the state of Maryland (MD) profoundly changed. The insurance provisions of the Patient Protection and Affordable Care Act (ACA) began implementation and a major revision of MD's Medicare waiver ushered in a Global Budget Revenue (GBR) structure for hospital reimbursement. Our objective was to analyze the impact of these policy changes on emergency department (ED) utilization, hospitalization practices, insurance profiles, and professional revenue. We stratified our analysis by the socioeconomic status (SES) of the ED patient population.
We collected monthly mean data including patient volume, hospitalization percentages, payer mix, and professional revenue from January 2013 through December 2015 from a convenience sample of 11 EDs in Maryland. Using regression models, we compared each of the variables 18 months after the policy changes and a six-month washout period to the year prior to ACA/GBR implementation. We included the median income of each ED's patient population as an explanatory variable and stratified our results by SES.
Our 11 EDs saw an annualized volume of 399,310 patient visits during the study period. This ranged from a mean of 41 daily visits in the lowest volume rural ED to 171 in the highest volume suburban ED. After ACA/GBR, ED volumes were unchanged (95% confidence interval [CI] [-1.58-1.24], p=.817). Hospitalization percentages decreased significantly by 1.9% from 17.2% to 15.3% (95% CI [-2.47%-1.38%], p<.001). The percentage of uninsured patients decreased from 20.4% to 11.9%. This 8.5% change was significant (95% CI [-9.20%-7.80%], p<.001). The professional revenue per relative value unit increased significantly by $3.97 (95% CI [3.20-4.74], p<.001). When stratified by the median patient income of each ED, changes in each outcome were significantly more pronounced in EDs of lower SES.
Health policy changes at the federal and state levels have resulted in significant changes to emergency medicine practice and finances in MD. Admission and observation percentages have been reduced, fewer patients are uninsured, and professional revenue has increased. All changes are significantly more pronounced in EDs with patients of lower SES.
2014年1月1日，马里兰州（MD）的医疗保健融资与服务提供发生了深刻变化。《患者保护与平价医疗法案》（ACA）的保险条款开始实施，MD州医疗保险豁免的重大修订引入了医院报销的全球预算收入（GBR）结构。我们的目标是分析这些政策变化对急诊科（ED）利用率、住院治疗情况、保险情况及专业收入的影响。我们按ED患者群体的社会经济地位（SES）对分析进行分层。
我们收集了2013年1月至2015年12月期间马里兰州11个急诊科的便利样本的月度平均数据，包括患者数量、住院率、付款人构成及专业收入。使用回归模型，我们将政策变化后18个月及六个月洗脱期的每个变量与ACA/GBR实施前一年进行比较。我们将每个急诊科患者群体的中位数收入作为解释变量，并按SES对结果进行分层。
在研究期间，我们的11个急诊科的年就诊量为399,310人次。范围从就诊量最低的农村急诊科平均每日41人次到就诊量最高的郊区急诊科的171人次。在ACA/GBR实施后，ED就诊量未变（95%置信区间[CI][-1.58 - 1.24]，p = 0.817）。住院率从17.2%显著下降1.9%至15.3%（95% CI [-2.47% - 1.38%]，p < 0.001）。未参保患者的比例从20.4%降至11.9%。这8.5%的变化具有显著性（95% CI [-9.20% - 7.80%]，p < 0.001）。每个相对价值单位的专业收入显著增加3.97美元（95% CI [3.20 - 4.74]，p < 0.001）。当按每个急诊科患者的中位数收入分层时，SES较低的急诊科中每个结果的变化更为显著。
联邦和州层面的卫生政策变化导致MD州急诊医学实践和财务状况发生重大变化。住院和观察比例降低，未参保患者减少，专业收入增加。所有变化在SES较低患者的急诊科中更为显著。
