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Emergency Room Utilization in the Navy

Emergency Room Utilization in the Navy. C. Allison Russo Kennell and Associates, Inc. Day 3 – June 6, 2012. Outline. Describe patterns of ER utilization in the MHS and Navy Medicine. Discuss special topics related to ER utilization analysis.

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Emergency Room Utilization in the Navy

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  1. Emergency Room Utilization in the Navy C. Allison Russo Kennell and Associates, Inc. Day 3 – June 6, 2012

  2. Outline • Describe patterns of ER utilization in the MHS and Navy Medicine. • Discuss special topics related to ER utilization analysis. • Discuss potential reasons for high ER utilization in the MHS and Navy Medicine. FOR OFFICIAL USE ONLY

  3. Why do we care? • Indicator of poor access, lack of continuity, patient education needs • Used by many payers as an indicator of quality • Can be costly • Evaluated by Services and HA/TMA in several formats for several purposes FOR OFFICIAL USE ONLY

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  14. Figure 1: MTF Prime enrollees have ER visit rates that are higher than the privately-insured and the uninsured* * As reported in Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010 Aug 11;304(6):664-70. 15

  15. Figure 2: Purchased care ER visits had higher intensity coding than MTF ER visits, FY 2011 16 FOR OFFICIAL USE ONLY

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  17. NYU Algorithm Total Navy ER Visits (FY11) N=2.7 million Injury 16% Classified by Algorithm 66.1% Classified by Algorithm 84% Non-Emergent 21% Emergent/Primary Care Treatable 35% Emergent – ED Care Needed – Preventable/Avoidable 5% Emergent – ED Care Needed – Not Preventable/Avoidable 22%

  18. Special Topics for ER Utilization Analysis FOR OFFICIAL USE ONLY

  19. How are ER records identified? • Purchased Care: • TED-NI (professional services) claims • Place of Service=23 and CPT codes 99281-99285 • Limit to 1 ER visit per person per day • Direct Care: • CAPER • CPT codes 99281-99285 and MEPRS Code starts with “BI” • Caution using TED-I (facility) claims • Caution using TED-NI claims without limiting to 1 person per day (double-counts any consults) • M2 Corporate Document available for ER visits FOR OFFICIAL USE ONLY

  20. What about Urgent Care Centers? • Can be defined using Place of Service code • Very inaccurate; most are coded as office visits • Apparent increases in UCC utilization is partially due to push by MCSC to code place of service better • From cost perspective, UCC use is better: same cost as an office visit • From quality/continuity perspective, UCC use can be a concern; however, very difficult to accurately id. FOR OFFICIAL USE ONLY

  21. Potential Population and Health System Factors That Increase ER Use • Population changes • Demographic changes • Socioeconomic status • Multiple chronic conditions • Outpatient capacity constraints: • Difficult for patients to obtain outpatient appointments • Longer average appointment waiting times • HMO enrollment • Other community differences • Regional practice variation • ER capacity • Population’s generic preferences and habits 22 FOR OFFICIAL USE ONLY

  22. Summary of Key Findings • The overall number of MHS ER visits is increasing (3.0M visits in FY2011) • When adjusted for changes in the eligible population, ER utilization increased 14% over seven years - 39% increase for purchased care and a 10% decline for direct care • ADDs have the highest ER visit rates, regardless of enrollment type • Annual ER visit rates for the Navy are lower than the Army's rates, averaging 465 visits per 1,000. • MTF PCM enrollees have 25 percent higher ER utilization than civilian PCM enrollees 23 FOR OFFICIAL USE ONLY

  23. Key Findings (cont.) • Prime enrolled ADDs have higher ER utilization than NADDs <65, regardless of PCM type, beneficiary location, age group, and gender. • Navy MTF Prime ER utilization exceeds the U.S. civilian rate by 23%; 64% higher among children <18 years old and 54% higher among females. • Non-emergent and primary care treatable conditions accounted for 56% of all ER visits in FY 2011 24 FOR OFFICIAL USE ONLY

  24. Key Findings (cont.) • ER utilization among ADDs is 60% higher than U.S. civilian rates • ER utilization rates among TRICARE Prime enrollees exceeds the rate for privately-insured and uninsured U.S. civilians • There is an increase in the intensity of ER visits, particularly among purchased care ER visits; yet, the mix of primary diagnoses has not changed significantly over time or between purchased and MTF care 25 FOR OFFICIAL USE ONLY

  25. Questions? Allison Russo: arusso@kennellinc.com

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