MedicalResearch.com: What are the main findings of the study?
Dr. Galarraga: This study examined how emergency department (ED) reimbursements for outpatient visits may be impacted by the insurance coverage expansion of the Patient Protection and Affordable Care Act as newly eligible patients gain coverage either through the Medicaid expansion or through health insurance exchanges. We conducted our analyses using the Medical Expenditure Panel Survey, a nationally representative survey managed by the Agency for Healthcare Research and Quality. We found that ED reimbursements for outpatient encounters by the previously uninsured who gain Medicaid insurance may increase by 17 percent and moving Medicaid-expansion ineligible patients to the private insurance market through insurance exchanges may increase reimbursements as high as 39 percent after the act is implemented.
MedicalResearch.com: Were any of the findings unexpected?
Dr. Galarraga: Although reimbursement increases from the uninsured obtaining new Medicaid insurance were expected to be minimal compared to obtaining new private insurance coverage, the overall magnitude of reimbursement increase, particularly for new private insurance, was less than anticipated. An important fact to consider with the findings of this study is that the Affordable Care Act (ACA) includes provisions that reduce disproportionate share hospital (DSH) payments. EDs have historically carried the bulk of the economic burden of uncompensated care, which has been balanced by DSH payments to hospitals. The ACA is projected to reduce Medicare and Medicaid DSH payments by $36 billion, or 50 percent, over 10 years. If the loss of DSH payment revenue exceeds the actual reimbursement increases with the insurance expansion, there may be a resultant loss in revenue for ED care.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Galarraga: The insurance expansion of the ACA may benefit EDs by increasing its reimbursements on the visit level. However, many factors will ultimately influence the economic health of EDs after health reform. Factors that may decrease ED revenue include the possibility of reduced disbursements from post-ACA private insurance products and the projected decline in DSH payments. Additionally, new delivery models, such as accountable care organizations and patient-centered medical homes, may alter the demand for ED services, and new payment models, such as bundled payments, may displace fee-for-service. It remains to be seen whether the increase in reimbursements with expanded insurance coverage will outweigh these other factors that may have an economic impact on emergency departments.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Galarraga: Future research should examine how the actual reimbursements change, and what EDs can do to remain competitive in the rapidly changing marketplace. Specifically, more research is needed on the new patient care delivery models proposed by the ACA to provide insight on its impact on the role of EDs in the provision of care, changes in ED patient volume, and its influence on ED reimbursement.
Galarraga JE, Pines JM.
Department of Emergency Medicine, George Washington University, Washington, DC.
Ann Emerg Med. 2013 Oct 23. pii: S0196-0644(13)01346-2. doi: 10.1016/j.annemergmed.2013.09.005. [Epub ahead of print]