Advertisement

Changes in Reimbursement to Emergency Physicians After Medicaid Expansion Under the Patient Protection and Affordable Care Act

      Study objective

      We examine the effect of Medicaid expansion on reimbursement for emergency physicians’ professional services.

      Methods

      We conducted a retrospective study using data from a national emergency medicine group in a sample of 50 emergency departments (EDs) from July 1, 2012, to June 30, 2015. We categorized facilities in 14 states into full-expansion (23), partial-expansion (17), and nonexpansion (10) categories based on pre-expansion Medicaid eligibility criteria for all adults. We used a difference-in-differences design to assess the effect of Medicaid expansion on provider reimbursement per visit. Secondary outcomes included reimbursement per relative value unit and relative value units per visit, both overall and by payer type, controlling for age, sex, billing codes, and health system relationship.

      Results

      We studied greater than 6.7 million ED visits during July 2012 to December 2015, 3.0 million pre-expansion and 3.7 million postexpansion. After adjusting for covariates, reimbursement per visit increased 6.3% (95% confidence interval 1.4% to 11.1%) in full-expansion relative to nonexpansion states and did not change significantly in partial-expansion versus nonexpansion states. Reimbursement per visit for commercial insurance increased 17.1% (95% confidence interval 9.9% to 24.2%) in full-expansion versus nonexpansion states. Reimbursement for self-pay visits increased 9.7% (95% confidence interval 3.7% to 15.7%) in full-expansion versus nonexpansion states. Changes in payments were driven by higher reimbursement per relative value unit; relative value units per visit declined slightly in full-expansion compared with nonexpansion states.

      Conclusion

      In this sample, full Medicaid expansion increased payments for emergency physicians’ professional services compared with reimbursement in nonexpansion states. Higher reimbursement was driven primarily by lower proportions of uninsured patients and increased reimbursement per visit for both commercially insured and self-pay patients in states with full Medicaid expansion.
      To read this article in full you will need to make a payment
      ACEP Member Login
      ACEP Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features.
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Carman K.G.
        • Eibner C.
        • Paddock S.M.
        Trends in health insurance enrollment, 2013-15.
        Health Aff (Millwood). 2015; 34: 1044-1048
        • Sabik L.M.
        • Cunningham P.J.
        • Tehrani A.B.
        Changes in emergency department utilization after early Medicaid expansion in California.
        Med Care. 2017; 55: 576-582
        • Klein E.Y.
        • Levin S.
        • Toerper M.F.
        • et al.
        The effect of Medicaid expansion on utilization in Maryland emergency departments.
        Ann Emerg Med. 2017; 70: 607-614.e1
        • Garthwaite C.
        • Gross T.
        • Notowidigdo M.
        • et al.
        Insurance expansion and hospital emergency department access: evidence from the Affordable Care Act.
        Ann Intern Med. 2017; 166: 172-179
        • Wherry L.R.
        • Miller S.
        Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: a quasi-experimental study.
        Ann Intern Med. 2016; 164: 795-803
        • Pines J.M.
        • Lotrecchiano G.R.
        • Zocchi M.S.
        • et al.
        A conceptual model for episodes of acute, unscheduled care.
        Ann Emerg Med. 2016; 68: 484-491.e3
        • Taubman S.L.
        • Allen H.L.
        • Wright B.J.
        • et al.
        Medicaid increases emergency-department use: evidence from Oregon's health insurance experiment.
        Science. 2014; 343: 263-268
        • Nikpay S.
        • Freedman S.
        • Levy H.
        • et al.
        Effect of the Affordable Care Act Medicaid expansion on emergency department visits: evidence from state-level emergency department databases.
        Ann Emerg Med. 2017; 70: 215-225.e6
        • Pines J.M.
        • Zocchi M.
        • Moghtaderi A.
        • et al.
        Medicaid expansion in 2014 did not increase emergency department use but did change insurance payer mix.
        Health Aff (Millwood). 2016; 35: 1480-1486
        • Freedman S.
        • Nikpay S.
        • Carroll A.
        • et al.
        Changes in inpatient payer-mix and hospitalizations following Medicaid expansion: evidence from all-capture hospital discharge data.
        PLoS One. 2017; 12: e0183616
        • Galarraga J.E.
        • Pines J.M.
        Anticipated changes in reimbursements for US outpatient emergency department encounters after health reform.
        Ann Emerg Med. 2014; 63: 412-417.e2
        • Carlson J.N.
        • Foster K.M.
        • Pines J.M.
        • et al.
        Provider and practice factors associated with emergency physicians’ being named in a malpractice claim.
        Ann Emerg Med. 2018; 71: 157-164.e4
        • Pines J.M.
        • Penninti P.
        • Alfaraj S.
        • et al.
        Measurement under the microscope: high variability and limited construct validity in emergency department patient-experience scores.
        Ann Emerg Med. 2018; 71: 545-554.e6
      1. Kaiser Family Foundation. Current status of state Medicaid expansion decisions. Available at: https://www.kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/. Accessed April 23, 2018.

        • R Core Team
        R: A Language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2013 (Available at:) (Accessed November 11, 2018)
        • Galarraga J.E.
        • Mutter R.
        • Pines J.M.
        Costs associated with ambulatory care sensitive conditions across hospital-based settings.
        Acad Emerg Med. 2015; 22: 172-181
        • Galarraga J.E.
        • Pines J.M.
        Costs of ED episodes of care in the United States.
        Am J Emerg Med. 2016; 34: 357-365
        • Blavin F.
        Association between the 2014 Medicaid expansion and US hospital finances.
        JAMA. 2016; 316: 1475-1483
        • Dobson A.
        • DaVanzo J.E.
        • Haught R.
        • et al.
        Comparing the Affordable Care Act's financial impact on safety-net hospitals in states that expanded Medicaid and those that did not.
        Issue Brief (Commonw Fund). 2017; 2017: 1-10
        • Glied S.
        • Chakraborty O.
        • Russo T.
        How Medicaid expansion affected out-of-pocket health care spending for low-income families.
        Issue Brief (Commonw Fund). 2017; 2017: 1-9
      2. Sawyer B, Cox C, Claxton G. An analysis of who is most at risk for high out-of-pocket health spending. Kaiser Family Foundation Brief, October 2017. Available at: https://www.healthsystemtracker.org/brief/who-is-most-at-risk-for-high-out-of-pocket-health-spending/. Accessed November 11, 2018.