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Medicaid beneficiaries face obstacles accessing timely follow-up care after ED visits

Patients without established primary care, particularly Medicaid beneficiaries, had difficulty obtaining follow-up appointments within 7 days of an ED visit, according to findings recently published in the Annals of Emergency Medicine.

“Many times, ED patients can be discharged but need outpatient appointments to continue treatment or obtain reassessment,” Shih-Chuan Chou, MD, MPH, department of emergency medicine, Brigham and Women's Hospital in Boston, told Healio Family Medicine. “Emergency physicians have long suspected that our patients, many of whom are indigent, have trouble getting timely follow-up in 1 week.”

Chou and colleagues used a secret shopper methodology to validate or disprove these suspicions. They asked two black men to call 53 primary care clinics in greater New Haven, Connecticut, over an 8-month period. These men requested follow-up care for uncontrolled, asymptomatic hypertension or nontraumatic acute lower back pain that had previously treated in the ED. The men also told the clinic they had one of several insurance plans — Medicaid, a state exchange plan, or traditional commercial insurance by either a state exchange insurer or commercial provider — to present as many scenarios as possible. The secret shoppers did not contact Veterans Affairs facilities, HIV and AIDS clinics and student health centers.

The primary outcome was the 7-day appointment rate. Secondary outcomes were appointment wait time and overall appointment rate. Data were adjusted for estimated equation models with binomial distribution.

Chou and colleagues found that of the 604 completed calls, the adjusted 7-day appointment rate was 30.7% (95% CI, 22.6-38.8), and the adjusted overall appointment rate was 68.2% (95% CI, 60.1-75.5). The overall median wait time among calls that led to an appointment was 8 days (interquartile range 2-19), with adjusted mean wait time of 16.4 days (95% CI, 12.9-20.7). When compared with commercial insurance, Medicaid calls had a lower adjusted 7-day appointment rate (25.5% vs. 35.7%; 95% CI, 2.2-18.1) and lower adjusted overall appointment rate (53.5% vs. 77.8%; 95% CI, 13.4-35.4).

“We honestly didn't expect that,” Chou said of the low rate of appointments for patients with commercial insurance. “We thought this would've been much higher based on review of prior studies done before the ACA, as well as a general impression that private insurance affords good access.”

Conversely, there was no significant difference between callers with commercial and state exchange insurance in 7-day appointment rates or overall appointment rates, Chou and colleagues wrote.

In addition, researchers stated that secondary analysis showed calls about lower back pain had a lower 7-day appointment rate than those about hypertension (27.6% vs. 33.7%; 95% CI, 1-11.2). However, there was no significant difference between overall appointment rates and adjusted mean appointment wait time across clinical conditions and insurance statuses.

The study’s overall results suggest it is difficult to get patients into the primary care health system when they need it most, according to Chou. He offered ways clinicians can increase a patient’s access to primary care.

“EDs should partner with local primary care providers so that patients who haven’t already established a primary care relationship can get the necessary ongoing care. This requires more robust information sharing and communication, which are just as important when patients are sent to the ED for expedited diagnosis, treatments, and, at times, admissions,” he said. “Each community will need to work with these partners so that patients are not lost between primary and emergency care.” – by Janel Miller

Disclosures : The authors report no relevant financial disclosures.