By Tara Mancini

Last month, another round of results were released by the Oregon Health Insurance Experiment (OHIE). The examination found that emergency department (ED) use increased by 40 percent among those who were enrolled in Medicaid compared to the control group.
The results raised an important and obvious question: what would ED usage look like when participants were insured longer than 13 months (the average time that OHIE participants were insured)?

The final evaluation of California’s Health Care Coverage Initiative (HCCI), released at the end of January by the UCLA Center for Health Policy Research, provides some insight into that question. HCCI, a three-year pilot program designed under a Bridge to Reform Waiver, was implemented in 10-counties with the goal of expanding access to care for uninsured Californians by building on the safety-net infrastructure.

Between 2007 and 2010 there were approximately 237,000 enrollees, a little more than two-thirds of whom received indigent care during the prior (baseline) year.

The data on ED visits that did not result in hospitalization (which is used as a proxy measure for potentially avoidable hospitalizations) suggest that longer enrollment periods contribute to lower rates of ED use.  Those who were enrolled for three years had rates that were about 1.6 times less than those who were enrolled for a shorter time period. While both groups experienced rate declines between the baseline year and the three-year program average, both groups experienced rate increases between the first and third year of the program (see graph below).

As noted above, not all program enrollees are included in the baseline year, but those in the baseline were more likely to have a chronic condition. This may have contributed to the decline between the baseline and the program years.

The data on chronic conditions looks to be heading in the right direction, however it only examines the overall rate. Between the baseline and third year of the program, the annual rate of ED visits that did not result in hospitalization declined for diabetes, asthma/COPD, and coronary arterial disease (CAD), although not for congestive heart failure (CHF).

Increased use of outpatient services and medical home adherence could account for the decrease in ED visits without hospitalization. Overall, there was a slight increase in the rate of specialist visits over three years and a slight decline in primary care provider visits; however, PCPs remained the most frequently used outpatient service. Three-year enrollees had higher rates of outpatient service use than those enrolled for a shorter time, both at baseline (8,305 and 6,190 per thousand) and for the three year average (7,974 and 6,614 per thousand).

There are some limitations to the data on medical homes, but the proportion of enrollees assigned to a medical home who always adhered to them increased during the program from 66.0 to 72.6 %. Of this population, 94.1% had no emergency room visits without hospitalization.

Educating enrollees on medical homes and promoting the use of outpatient care are just a few of the steps that the HCCI took to increase the use of appropriate care. Similarly, Oregon has begun to take some of the same steps under its Coordinated Care Organizations. The preliminary results indicate that Oregon’s efforts are having an impact reducing, as ED visits by Medicaid patients were reduced by 9% after the first year.

The experiences of Oregon and California illustrate how it takes time and investment from both the health system and enrollees to reduce unnecessary or avoidable use of the ED. Health systems can build their capacity and improve care coordination, enrollee retention, and education, while enrollees can learn how to better navigate the health system and self-manage chronic conditions. But we can’t expect that it will happen overnight.

 Note: Health Affairs recently released an article noting that while some OHIE enrollees reported improved health status shortly after becoming insured, others reported that health improvements after extended periods of care coordination.