Copays Don't Reduce Medicaid Non-urgent ED Visits, Study Says

Data from a 10-year study does not show any increase in the rate of Medicaid patients' visits to doctors' offices. A shortage of primary care physicians willing to accept Medicaid may be a factor.

Slapping copayments on emergency department visits by Medicaid patients seeking non-urgent care does little or nothing to reduce the costly practice, research shows.

A study this week by Johns Hopkins researchers published in JAMA Internal Medicine tracked the use of the emergency department for Medicaid non-urgent care from 2001–2010 in eight states where hospitals were authorized to charge copayments. Researchers compared ED utilization in those eight copay states with those of 10 states where hospitals were not authorized to charge ED copayments.

"With respect to this particular study, we can say that cost-sharing in the ED did not have an impact and that has implications for how cost-sharing is approached in Medicaid moving forward," says study lead author Mona Siddiqui, MD, MPH, assistant professor of internal medicine at the Johns Hopkins University School of Medicine.

ED copays were authorized by Congress in 2005 as part of the Deficit Reduction Act with the hope of steering Medicaid patients to less-costly care venues. Researchers sampled about 3,000 Medicaid patients in Florida, Kentucky, Minnesota, Montana, Ohio, Pennsylvania, South Carolina and Washington, that charged copayments of $3 to $15 for non-urgent ED visits.

They also sampled about 7,500 Medicaid recipients in 10 states—California, Colorado, Connecticut, Georgia, Louisiana, Maryland, Michigan, North Carolina, Virginia and Texas—that did not charge copayments.

The study found that the states with the highest initial rates of ED use also sought copayments from Medicaid recipients for non-urgent care. When the copayments went into effect, however, rates of ED use in those states went down less than one-tenth of 1%. The data did not show any increase in the rate of Medicaid patients' visits to doctors' offices.

Possible Contributing Factors
"It's remarkable that over the 10-year period that we used the data for, cost-sharing did not have an impact," Siddiqui says. "We could postulate as to a couple of things that are underlying the findings. Number one, a lot of patients may not be aware of those copayments and so that's playing a bit of a factor."

"Another issue here is how do we actually define non-urgent care? We know there is no agreed-upon definition from a provider perspective and I don't think a lot of patients would feel comfortable saying when something is not urgent as opposed to urgent."

Siddiqui says the burden of determining if patients' ailments were non-urgent was placed on emergency department clinicians during the initial triage. "Oftentimes it can be difficult at that point to determine whether something is urgent or not urgent," she says.

"The minimal effort it may take to complete that service encounter doesn't completely equate with the minimal amount of cost-sharing charge, and the hospital's administrative paperwork."

Siddiqui says many Medicaid patients seek care in the ED because they can't find a primary care physician.

"We know there is a shortage of Medicaid-accepting providers," she says. "When a patient comes to the ED and a provider deems an episode non-urgent, they have to provide the patient with a list of acceptable Medicaid-accepting providers, which isn't always easy."

The Johns Hopkins study predates Medicaid expansion under the Patient Protection and Affordable Care Act. But Siddiqui says the findings remain relevant.

"There is an increased burden on Medicaid and states taking an increasing share of costs," she says. "States are concerned about the sense of personal responsibility to shape the way patients utilize the healthcare system. That is a question that hasn't changed for states or for the federal government."

"This study shows that co-payments for emergency department non-urgent care visits were ineffective in getting people to see a primary care provider more. These questions are still persistent in terms of how do we get patients to have better preventive care instead of going to the ED for their usual source of care."

Siddiqui says Medicaid expansion reaffirms the importance of access to primary care. "The shortage that we know exists of primary care providers in a lot of rural areas and in Medicaid-heavy populations plays a huge role in patients then not being able to seek care with a longitudinal provider," she says.