By Joshua Tamayo-Sarver, MD, PhD, FACEP
It's halfway through 2014, and the Reform Realtime data set has matured considerably. This means we're now able to make more meaningful comparisons by controlling for factors like month, year, hospital and geographic location. We're also able to more confidently identify patients covered by state and federal health exchanges.
Being a numbers guy, I'm really excited about this. I've been really curious about the impact of reform on ED volumes (which appear to be rising) and reimbursement (which we all hope will rise).
But as often happens with data, once I started running ours through computer models, I found something unexpected, but equally interesting:
Patients covered through state and federal health exchanges were more likely to present to the ED with high-acuity conditions.
In fact, their overall acuity (on a 5-point scale) was 4.10 versus 3.98 for the non-exchange population. These numbers hold even when controlling for factors like gender and age.
Now are those 1.12 points meaningful? Statistically, yes. One of the great things about Reform Realtime is that we've got quite a big data set that includes over 1.75 million patients so far in 2014. So it's very unlikely that the increased acuity among exchange patients can be explained by mere coincidence.
Perhaps the more interesting question is clinical significance. Are the exchange patients noticeably more ill to those caring for them? If so, these findings could have a very real impact on emergency care — especially at EDs that struggle with crowding and throughput.
On clinical significance, the numbers are more equivocal, but we can still draw some conclusions.
Overall, exchange patients presenting to the ED tended to be more acute. However, they weren't any less stable than the non-exchange group. In fact, they were slightly less likely to be admitted to the hospital from the emergency room. So the increase in acuity probably isn't due to more exchange patients presenting with emergent conditions like trauma, heart attack or end-stage cancer.
To me, that strongly suggests that the increase in acuity is actually driven by medical complexity. In other words, more of the exchange patients are presenting to EDs with multiple chronic conditions.
Granted, to really confirm this, I'd need to drill down into the diagnosis data. But these findings square with the anecdotal evidence we're hearing from some EDs. They also support the predictions some practicing emergency physicians have been making all along. Take this one from a Reform Realtime video posted back in May 2014:
"So in the short-term, I think we are going to see many patients who are getting insurance for this first time whose medical problems have been building for many years, and they've been holding out. Our acuity might go up short-term."
- Jeff Bass, MD, emergency physician
I would tend to agree with Dr. Bass' reasoning. Research suggests that 25 percent of uninsured adults go without needed care. So this increase in medically complex exchange patients may represent a release of pent-up need among the newly insured. And the fact that these patients present to the ED rather than primary care doctors suggests that ongoing barriers to access need to be addressed.
Now as always, this analysis is subject to a few caveats. Most importantly, we are sure when we identify a health exchange patient that they are truly a health exchange patient, but we have been able to identify only a small fraction of all the health exchange patients. We've confidently identified about 9,155, who represent about 0.06 percent of all CEP America ED patients in our dataset. This means that we are able to say something about what health exchange patients look like, but we are unable to say much about volume or payment.
So there you have it: the most unexpected finding to come out of Reform Realtime so far. It took me by surprise, which was a lot of fun.
And the volume and payment data? Well, believe it or not, the computer's still crunching the numbers on overall volume effects. And our health exchange reimbursements have been very slow to come in — which is pretty typical when the billing department works with new payers and processes. But I do think we're closing in on both, so stay tuned.
Have you noticed a change in acuity at your ED? If so, comment below and tell us about it.
Joshua Tamayo-Sarver, MD, PhD, FACEP, is director of clinical data analysis and research at CEP America, overseeing the organizational data strategy, evaluating the effects of programs and practices and leveraging data to provide the information needed for CEP to provide the highest quality and most efficient patient care. Dr. Tamayo-Sarver joined CEP America in 2008 as a fellow in administration and data. In addition to being the director of clinical data analysis and research, he works as a staff physician in the emergency department at Good Samaritan Hospital in San Jose, Calif., where he is also vice chairman of the emergency department and director of quality improvement. He holds a bachelor's degree with honors in biochemistry from Harvard University, a medical degree from Case Western Reserve University and a certificate in medical informatics from Oregon Health Sciences University. Dr. Tamayo-Sarver completed his PhD at Case Western Reserve University in epidemiology and biostatistics, where his dissertation was the development and publication of a novel model describing how physicians make clinical decisions in practice. He completed his residency in emergency medicine at Harbor-University of California, Los Angeles. He also spent a year working as an EMT and health educator in El Salvador. He is board-certified in both emergency medicine and clinical informatics.