Denham Alina, Hill Elaine L, Raven Maria, Mendoza Michael, Raz Mical, Veazie Peter J
Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, USA.
Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, USA.
Health Econ Policy Law. 2024 Jan;19(1):73-91. doi: 10.1017/S1744133123000270. Epub 2023 Oct 23.
Policies to decrease low-acuity emergency department (ED) use have traditionally assumed that EDs are a substitute for unavailable primary care (PC). However, such policies can exacerbate ED overcrowding, rather than ameliorate it, if patients use EDs to complement, rather than substitute, their PC use. We tested whether Medicaid managed care enrolees visit the ED for nonemergent and PC treatable conditions to substitute for or to complement PC. Based on consumer choice theory, we modelled county-level monthly ED visit rate as a function of PC supply and used 2012-2015 New York Statewide Planning and Research Cooperative System (SPARCS) outpatient data and non-linear least squares method to test substitution vs complementarity. In the post-Medicaid expansion period (2014-2015), ED and PC are substitutes state-wide, but are complements in highly urban and poorer counties during nights and weekends. There is no evidence of complementarity before the expansion (2012-2013). Analyses by PC provider demonstrate that the relationship between ED and PC differs depending on whether PC is provided by physicians or advanced practice providers. Policies to reduce low-acuity ED use via improved PC access in Medicaid are likely to be most effective if they focus on increasing actual appointment availability, ideally by physicians, in areas with low PC provider supply. Different aspects of PC access may be differently related to low-acuity ED use.
传统上，减少低急症急诊科（ED）就诊率的政策一直假定急诊科是无法获得的初级保健（PC）的替代品。然而，如果患者使用急诊科是为了补充而非替代其初级保健的使用，那么这类政策可能会加剧急诊科的拥挤，而不是缓解拥挤状况。我们测试了医疗补助管理式医疗的参保者是否因非紧急且可由初级保健治疗的病症前往急诊科，以替代或补充初级保健。基于消费者选择理论，我们将县级每月急诊科就诊率建模为初级保健供给的函数，并使用2012 - 2015年纽约州全州规划与研究合作系统（SPARCS）的门诊数据以及非线性最小二乘法来测试替代与互补关系。在医疗补助扩张期之后（2014 - 2015年），全州范围内急诊科和初级保健是替代品，但在高度城市化和较贫困的县，夜间和周末期间它们是互补品。在扩张之前（2012 - 2013年）没有互补关系的证据。按初级保健提供者进行的分析表明，急诊科和初级保健之间的关系因初级保健是由医生还是高级执业提供者提供而有所不同。如果通过改善医疗补助中的初级保健可及性来减少低急症急诊科就诊率的政策，聚焦于在初级保健提供者供给低的地区增加实际预约可及性（理想情况下由医生提供），那么这些政策可能最有效。初级保健可及性的不同方面与低急症急诊科就诊率的关联可能不同。
