Narrowing the gap - Decreasing emergency department use by children enrolled in the Medicaid program by improving access to primary care

Objective: To evaluate the effectiveness of increased primary care access created by North Carolina's Medicaid managed care plan, Carolina Access (CA), in reducing unnecessary emergency department (ED) use in Guilford County. Methods: Emergency department records of pediatric visits before and after the implementation of CA were analyzed. Variables included patient age, International Classification of Diseases, Ninth Revision discharge diagnosis, insurance status, date of visit, time of visit, and ZIP code. Visits were classified as either urgent or nonurgent based on discharge diagnosis. Rates of ED use per 1000 persons were calculated using county population and Medicaid enrollment figures. Results: A total of 54742 ED visits occurred between January 1, 1995, and December 31, 1997. Thirty-eight percent of these visits were by children (defined as those aged 0-18 years in this study) enrolled in the Medicaid program. After the implementation of CA, monthly ED rates per 1000 children with Medicaid insurance decreased 24% from 33.5 +/-5.3 to 25.6+/-2.3 (P<.001),which translates to 158 fewer visits per month by children enrolled in the Medicaid program. Nonurgent visits among the population enrolled in the Medicaid program decreased from an average monthly rate per 1000 of 17.9+/-3.5 to 11.2+/-2.5 after the implementation of CA (P<.001), accounting for most of the decrease in total visits. (All data are given as mean+/-SD.) The rates of total and nonurgent visits among the population not enrolled in the Medicaid program increased slightly. Conclusions:: For children with Medicaid insurance, we found a strong temporal relation between decreased visits to the ED and increased access to primary care services, services that were made available by the implementation of North Carolina's Medicaid managed care plan, CA. Specific services that may be responsible for the decreased ED use include the expanded availability of primary care physicians and the use of telephone triage systems. No similar decrease in ED use was seen among the non-Medicaid-insured group.