Preliminary Report of Hospital Emergency Department Use in Travis and Williamson Counties

 1999 – 2001 

 

 

 

 

 

 

 

June 2002

 

 

Executive Summary

 

 

In a continuing series of studies and analyses for the communities of Central Texas, the Indigent Care Collaboration (ICC) recently participated in a study of Emergency Department (ED) data of eight area hospitals in Travis and Williamson counties. 

 

The following key questions were addressed by this analysis:

 

 

v     Who uses Hospital Emergency Departments?

 

Hospital emergency departments are used by commercially insured, self-pay, Medicaid, and Medicare and other populations.  Among adults, almost half the visits to emergency departments (297,000 over the three year period) were commercially insured, followed by nearly 200,000 self-pay, 43,000 Medicaid, and 74,000 for all other populations. 

 

Over the course of the three-year period, visits by all patients increased by nearly 10%, from 293,000 visits in 1999 to 322,000 in 2001. 

 

v     Which populations account for the increase in Hospital Emergency Department Use?

 

Overall, hospital emergency department use increased by 5.4% between 1999 and 2000 among adults (ages 18-64), and by 4.0% between 2000 and 2001.   Around 75% of the increase in adult use from 1999-2000 was attributable to an increase in commercially insured patients, but approximately 95% of the increase from 2000-2001, which was roughly the same time frame when area primary care providers began to report severe stress on their systems of care, was attributable to an increase in self-pay or Medicaid patients.

 

Emergency department use increased by 3% from 1999 to 2000 among children (age 0 –17) and 8.6% between 2000 and 2001.   Most of the overall increase in use by children occurred among children either on Medicaid or other governmental sources of support, including the State Children’s Health Insurance Program (SCHIP). 

 

 

 

 

 

 

 

 

v     Are self-pay (i.e., uninsured) patients more likely to use Emergency Departments?

 

Self-pay patients are more likely to use emergency departments.  While the largest number of users of emergency departments is that of the commercially insured, the most over-represented group using hospital emergency departments is the self-pay group, which for the adult population accounts for 32% of the visits but only 26% of the adult population in Travis county, and only 22% of the adult population in Williamson county.

 

 

v     Are self-pay patients more likely to misuse Emergency Departments?

 

This research is not designed to measure “misuse” of emergency departments.  These data do suggest, however, that self-pay patients utilize the emergency departments in the same manner that commercially insured patients use emergency departments.   Just as in the commercially insured population, approximately half of the visits for self-pay patients were found in the analysis to be preventable or avoidable, and half were found to be emergent¹.  Utilization patterns by time of day and by gender were also very similar between self-pay and commercial patients.

 

On the other hand, for both uninsured children and the entire non-elderly Medicaid population, most of the ED visits were considered preventable, and gender and utilization patterns are generally distinct from either self-pay or commercial patients.

 

 

v     What can be done to reduce burden on hospital emergency departments?

 

There is no single solution to this complex problem.  However, we estimate from this analysis that 20,000 to 30,000 excess visits to emergency departments among self-pay adults would be handled in community-based settings if more community-based non-emergency care were available and accessible to this population.  The problem is that safety net primary care providers are already overstressed – a recent ICC report indicated that they are already 6% over capacity.  While providers have stepped forward, increasing clinic capacity and planning the launch of Project Access, it is clear that more will need to be done.  Because all classes of patients are in the emergency departments together, system and region-wide solutions will be needed that affect us all.

 

¹As defined by the NYU ED data algorithm.   See Introduction for algorithm definitions.

 

Introduction

 

 

As a companion to an earlier report reviewing use and capacity in Travis County safety net primary care providers, the ICC undertook an analysis of emergency department use in a set of Travis and Williamson County hospitals that are part of either the Seton or St. David’s systems.  The Austin-owned, but Seton-operated, Brackenridge Hospital was also included as part of the analysis. 

 

The ICC conducted their analysis based upon an Emergency Department (ED) data algorithm developed by the Center for Health and Public Service Research at the Robert F. Wagner School of Public Service at New York University (NYU).   The ICC membership includes the St. David’s Health Care Partnership network as well as the Seton Healthcare Network, so hospital ED data from 1999 through 2001 for these hospital systems were subjected to the NYU data algorithm.

 

The NYU algorithm categorizes ED visits into one of four categories.  These categories were developed based on sample ED data that captured a patient’s initial complaint, vital signs, procedures performed and resources used in the ED, and the final discharge diagnosis.   Alcohol and drug related diagnoses, mental health diagnoses, injuries and poisonings and anything that is not classified on the ED record are tracked in separate categories as “Other” ED visits.  The four categories are defined as:

 

v     Non-Emergent – based on information on the record, care was not needed within 12 hours. 

 

v     Emergent, Primary care treatable – treatment was required within 12 hours, but care could have been provided in a primary care setting. 

 

v     Emergent, ED Care required but Preventable/Avoidable – emergency care was needed, but the condition may have been potentially preventable or avoidable had effective or timely primary care services been available, such as a diabetic flare-up.

 

v     Emergent/ED Care need, not Preventable/Avoidable – emergency care was needed and could not have been prevented, such as appendicitis or heart attacks.

 

The first three categories listed above are considered “preventable” visits for the purposes of this report.  

 

 

The eight hospitals that were included in the Austin area sample were:

 

v     South Austin Hospital

v     Seton Medical Center

v     Seton Northwest

v     Round Rock Medical Center

v     St. David’s Medical Center

v     Brackenridge Hospital

v     Children’s Hospital of Austin, and

v     North Austin Medical Center

 

While these are not all the hospitals that form the emergency department safety net in the two-county region, together they account for a large percentage of all emergency department care, and especially care for the uninsured.

 

The data gathered for this report included data about children, adults, and elders, including commercially insured, Medicaid, self-pay, and other populations. The primary focus of this report, in keeping with the mission of the ICC, however is on the use patterns of the uninsured, or self-pay adult population.  While most of the conclusions that can be drawn from the data will be left to the reader, it will be clear that meeting the needs of the uninsured present some vexing problems to providers and policy leaders alike, both the Medicaid and commercially insured populations present challenges of their own, and these will also need to be addressed as part of any local community system-wide solution.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Narrative

 

 

Utilization

 

Hospital ED use overall increased by 10%, from nearly 293,000 visits in 1999 to over 322,000 visits in 2001, in a sample of eight hospitals serving Travis and Williamson Counties. 

 

65% of visits to EDs during this three-year period from 1999 to 2001 were by adults, (ages 18 to 64.)  Almost one-third of the visits were by children (age 0 to 17).  The remaining small percentage was for elders (age 65 and older.)  Among all three groups combined, ED visits increased by 4.6% between 1999 and 2000, and by 5.4% between 2000 and 2001.   See Figure 1.

 

 

Figure 1

 

 

Between 1999 and 2001, the hospitals in the study experienced an increase in ED use by adult patients from over 185,000 visits to over 203,000 visits.  ED use among adults increased by 5.4% (as previously reported) from 1999 to 2000, and by 4.0% from 2000 to 2001.  Over three quarters of the increase in between 1999 and 2000 was attributable to an increase in the number of commercially insured patients seen, but nearly 95% of the increase between 2000 and 2001 was attributable to an increase in the number of self-pay and Medicaid patients seen.   See Figure 2.

 

Figure 2

 

The task of absorbing the increase in self-pay adult patients over the two-year period was distributed among the hospitals in the study.  Among self-pay adult patients using the ED, the greatest growth between 1999 and 2001 was in Round Rock.  The largest growth in use between 2000 and 2001 occurred in St. David’s and Brackenridge.  The most consistent growth during the two-year period occurred in Round Rock, St. David’s, and North Austin.

 

Self-pay patients accounted for approximately one-third of ED visits during all three years.  However, the percentage of uninsured persons in the population at large was estimated to be between 20% and 25% of the population during the study years.  If the additional percentage were considered to be a measure of “excess” ED use among that population, then an estimated 20,000 to 25,000 visits in 2001 could have been handled in primary care settings, if there had been more room there.

 

The actual number of visits for children increased from over 87,000 in 1999 to almost 90,000 in 2000 to over 97,000 in 2001.  Most of the increase between 2000 and 2001 occurred among children either on Medicaid or other governmental sources of support, including SCHIP.

 

Uninsured patients are over-represented in Hospital Emergency Departments, and this means a more substantial part of their cost of care must be absorbed by the hospitals directly.  Historically, hospitals have been able to shift some of this burden to commercial insurers, but over the past two decades, with both managed care and utilization review more prominent parts of the health care landscape, cost-shifting has been much more limited.  In addition, with fewer than half the patients paying “full freight” to begin with, there are fewer commercial insurers to whom any costs can be shifted at all.

 

The two largest groups of adult ED users were commercially insured patients (49%) and self-pay, or uninsured, patients (32%).  The remaining users were Medicaid patients or those covered by other sources of funding.  Overall, these percentages suggest that self-pay patients are over represented in the EDs, and commercially insured patients are under represented.

 

For the three year time period, for adults (age 18-64):

 

v     Commercially insured patients had just over 297,000 visits (49% of all ED visits)

v     Self-Pay patients had just under 200,000 visits (32%)

v     Medicaid patients had just over 43,000 visits (7%)

v     Patients of all other payer types had just over 74,000 visits (12%) 

 

Data from the Kaiser Family Foundation for 1999-2000 indicate that 68% of adults (age 19-64) in Texas had commercial health insurance through an employer or individual insurance policy.  According to the most current data available from the Texas Department of Health, 26% of the adult population (19-64) in Travis County in 1999 had no health insurance, and 9% of the area’s population was Medicaid eligible.  For Williamson County, 22% of the adult population had no health insurance and 5% were Medicaid eligible in 1999. 

 

 

Avoidable versus Emergent Visits

 

The algorithm utilized in this ED use analysis does not measure misuse or inappropriate use of Emergency Departments in and of itself.  Non-emergent ED visits may reflect a provider shortage, a patient’s lack of understanding as to how to manage their chronic disease, or a care seeking preference of the patient in general.

 

 

 

About half the ED visits for the entire commercially insured population were considered preventable.  In addition, about half the visits for the adult self-pay population were considered preventable.  However, for both uninsured children and the entire non-elderly Medicaid population, most of the ED visits were considered preventable.

 

For example, in 2000, 51% of all ED visits by commercially insured adult patients were for emergency visits that the study’s analysis determined to be preventable or avoidable, while 49% were considered emergent.    The exact same ratio of preventable/avoidable to emergent visits was found for adult self-pay patients -- 51% preventable or avoidable, and 49% emergent. The ratios were nearly identical in 2001 as well, with commercial adult visits split between 51% preventable and 49% emergent, while self-pay adults in 2001 had 52% preventable visits and 48% emergent visits.   See Figure 3.  

 

Figure 3

 

The adult Medicaid population utilization was different, however, with 62% of all adult Medicaid ED visits being preventable and 38% being true emergencies.  In other words, the data suggest that even though adult Medicaid recipients often have a primary care provider and/or a source for primary care services, they are still more likely to use hospital emergency departments than either the uninsured or commercially insured individuals.

 

 

For children, a clear majority of ED visits were considered preventable for both the Medicaid and the self-pay populations, but not so for the commercially insured child.  See Figure 4.  74% of all Medicaid visits for children and 65% of all Self-pay children ED visits were preventable.  Commercially insured children ED visits, however, were equally divided between preventable and emergent visits (50% to 50%). 

 

 

Figure 4

 

 

A further breakdown of these data reveal that the total preventable visits are primarily comprised of Non-Emergent and Emergent but Primary Care treatable visits, as shown in Table 1.    This utilization pattern may reflect all parents’ anxieties when faced with a child with a high fever, a recurring ear infection, or perhaps a serious stomach virus.    If primary care clinics are closed, or an appointment is not available and/or a nurse triage call center hotline services are unavailable, the parent may see the ED as their best option.

 

 

Table 1

Breakdown of Total Preventable ED Visits

Among Children Age 0-17 by Payer

 

Payer Type	Non-Emergent	Emergent, Primary Care Treatable	ED Care Needed, but Preventable
Medicaid	27%	37%	10%
Self Pay	25%	31%	8%
Commercial	20%	22%	8%

 

 

 

Time-of-Day Use Patterns

 

The adult population utilization patterns for the ED by time of day are also very similar for self-pay and commercially insured patients, with only minor variations.  Generally, the percentages of preventable visits were at their peak in the mornings but decreased throughout the day when access to community-based primary care services should have been more available.  Commercial patient’s percentage of preventable visits increased again during the overnight hours (10pm to 6am), while the increase for self-pay patients during this time period was more often for truly emergent visits than preventable visits.  See Figures 5 and 6.

 

Figure 5

 

 

Neither of these trends held true of the Medicaid population, however, where the time of the visit made little difference in whether or not it was determined to be preventable.  For the adult Medicaid population, the data are consistent and nearly constant throughout the day.   Regardless of the time, 60-63% of all adult Medicaid visits are preventable while 37-40% are emergent.

Figure 6

 

 

 

Gender Use Patterns

 

The ED utilization patterns were also similar between the commercial and Self-pay adults in terms of gender.   Fifty-eight (58%) of the total adult self-pay ED visits by females were preventable versus 41% that were emergent, while 44% of all adult self-pay visits by males were preventable versus 56% that were emergent.  For commercially insured adults, the numbers were nearly identical, with 56% of female visits being preventable versus 44% emergent, while male visits were 45% preventable versus 55% emergent.

 

Again, the Medicaid adult population varied slightly in their utilization patterns by gender from the self-pay or commercially insured adult patients.  Both male and female adults on Medicaid had higher rates of preventable visits than emergent visits with 55% and 45% for males, and 63% versus 37% for females.