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.

• Discuss potential reasons for high ER utilization in the MHS and Navy Medicine.

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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

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Table 1a: The overall number of ER visits and network ER visits in the MHS

increased, but MTF ER visits slightly decreased, FY 2004-2011

FY 04 FY 11 % Change

Purchased Care 1.2M 1.8M 54%

Direct Care 1.2M 1.2M -1%

Total 2.4M 3.0M 26%

Note: Includes ADSMs, ADDs, and NADDs<65 in CONUS.

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Table 1b: Even when adjusted for population changes, ER visit rates in the MHS increased for network care

and decreased for direct care, FY 2004-2011ER Visits/1000

FY 04 FY 09 % ChangePurchased Care 209 290 39%Direct Care 215 193 -10%Total 423 483 14%Note: Includes ADSMs, ADDs, and NADDs<65 in CONUS. Rates have been adjusted to account for OHI use among ADDs and NADDs<65 not enrolled in TRICARE Prime.

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Table 2: MHS-wide, ADDs have the highest rate of ER visits, but ADSMs experienced the

largest increase from FY 2004-2011ER Visits/1000

Beneficiary Category FY 04 FY11 % Change

ADSMs 363 452 25%

ADDs 537 663 23%

NADDs <65 359 359 0%

423 483 14%Note: Includes purchased care and direct care. Rates have been adjusted to account for OHI use among ADDs and NADDs<65 not enrolled in TRICARE Prime.

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Table 3: Annual ER visit rates for the Navy are lower than the Army's rates, FY 2011

ER Visits/1000Type of

Enrollees Navy Army Air Force MHS

ADSMs 378 527 430 452

ADDs 658 714 564 663

NADDs <65 363 382 327 359

Total 465 540 417 483Note: Includes purchased care and direct care. Rates have been adjusted to account for OHI use among ADDs and NADDs<65 not enrolled in TRICARE Prime.

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Table 4: Annual ER visit rates are highest for enrollees with a MTF PCM, FY 2011

ER Visits/1000Beneficiary

Category MTF PCM Civ PCM Not Prime Total

ADSMs 435 343 N/A 452

ADDs 674 550 888 663

NADDs <65 404 317 364 359

Total 513 412 494 483Note: Includes purchased care and direct care. Rates have been adjusted to account for OHI use among ADDs and NADDs<65 not enrolled in TRICARE Prime.

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Table 5: Among enrollees with a MTF PCM, Navy ER visit rates are lower than the Army's rates for

all beneficiary categories, FY 2011ER Visits/1000 (MTF PCM)

Type of Enrollees Navy Army Air Force MHS

ADSMs 369 498 422 435

ADDs 671 740 582 674

NADDs <65 400 434 380 404

Total 481 583 467 513Note: Includes purchased care and direct care. Rates have been adjusted to account for OHI use among ADDs and NADDs<65 not enrolled in TRICARE Prime.

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Table 6: Annual ER visit rates are higher for enrollees with a Navy MTF PCM even in inpatient catchment areas,

FY 2011ER Visits/1000

Beneficiary Location MTF PCM Civ PCM

IP catchment areas 476 449

Non-catchment areas 504 395

Prism, non-catchment area 401 383

Non-prism, non-catchment area 1311 401

Note: Includes purchased care and direct care.

Table 7a: Among Navy Prime enrollees, ADDs had higher ER utilization than NADD <65, regardless of PCM type, beneficiary

location, age, and gender, FY 2011MTF PCM Civ PCM

ER Visits/1000 ER Visits/1000

Beneficiary Characteristics ADD NADD <65 ADD NADD <65Total Prime Enrollees: 671 400 569 317Beneficiary Location:IP catchment areas 668 414 579 328Non-catchment areas 687 326 556 310Prism, non-catchment area 585 300 538 301Non-prism, non-catchment area 1793 476 565 314

Age Group:00-04 930 648 732 46105-14 417 352 350 25615-17 432 378 378 29518-24 952 456 833 38525-34 736 682 669 60635-44 520 412 466 35745-64 459 388 424 295

Gender:Females 695 453 597 359Males 623 349 515 274

Note: Includes purchased care and direct care.

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Table 8: Enrollees with an Navy MTF PCM have ER visit rates that are more than 20 percent higher than

the US civilian average, FY 2011ER Visits/1000

Navy MHSU.S.

Population*

MTF PCM Civ PCM Navy Total MHS Total U.S. TotalTotal ER visits: 481 421 465 483 391Visits by age: <18 years 592 432 511 511 36218-44 years 463 525 508 548 43345-64 years 377 298 345 348 317

Visits by sex:Female 635 474 559 569 414Male 383 354 380 405 361

Note: MHS includes purchased care and direct care. Rates have been adjusted to account for OHI use among ADDs and NADDs<65 not enrolled in TRICARE Prime.* 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.

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Table 9: ADDs have ER visit rates that are nearly 70 percent higher than the U.S. civilian average

ER Visits/1000

NavyU.S.

Population* ADSM ADD NADD <65 Navy Total U.S. Total

Total ER visits: 378 658 363 465 391Visits by age: <18 years NA 591 326 511 36218-44 years 382 766 447 508 43345-64 years 291 528 341 345 317

Visits by sex:Female 684 689 413 559 414Male 332 597 311 380 361

Note: MHS includes purchased care and direct care. Rates have been adjusted to account for OHI use among ADDs and NADDs<65 not enrolled in TRICARE Prime.

* 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.

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Figure 1: MTF Prime enrollees have ER visit rates that are higher than the privately-insured and the uninsured*

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* 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.

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Figure 2: Purchased care ER visits had higher intensity coding than MTF ER visits, FY 2011

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Table 8: Top 10 ER visit diagnoses in FY11 in the Direct Care system compared to the Purchased Care system

Direct Care Rank DX Description

% of all DC ER Visits Cum %

PC Rank of this DX

% of all PC ER Visits

1 465 Acute upper respiratory infections 4.8% 5% 4 2.6%2 780 General symptoms 4.0% 9% 3 5.1%3 786 Symptoms invl respiratory sys & oth chest symp 3.9% 13% 1 5.6%4 789 Oth symptoms invl abdomen & pelvis 3.7% 16% 2 5.4%5 787 Symptoms invl digestive sys 3.2% 20% 5 2.5%6 462 Acute pharyngitis 2.8% 22% 9 1.9%7 382 Suppurative and unspecified otitis media 2.6% 25% 7 2.2%8 724 Oth unspecified dis of back 2.4% 27% 8 1.9%9 599 Oth dis of urethra and urinary tract 2.2% 30% 12 1.8%

10 079 Viral and chlamydial infection 2.1% 32% 20 1.1%

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Total Navy ER Visits (FY11)N=2.7 million

Injury16%

Classified by Algorithm66.1%

Non-Emergent21%

Emergent/Primary Care Treatable

35%

Emergent – ED Care Needed – Preventable/Avoidable

5%

Emergent – ED Care Needed – Not Preventable/Avoidable

22%

Classified by Algorithm84%

NYU Algorithm

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Special Topics for ER Utilization Analysis

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 visitsFOR OFFICIAL USE ONLY

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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.

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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

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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

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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

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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

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Questions?Allison Russo: arusso@kennellinc.com

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