1 Improving Care for the Uninsured by Providing Links to Primary Care Susan H. Busch, Ph.D. 1 Sarah McCue Horwitz, Ph.D. 2 Kathleen M. B. Balestracci, Ph.D. 1 Jim Rawlings, M.P.H. 1 1 Health Policy & Administration, Yale University, and 2 Department of Psychiatry, Case Western Reserve Medical School

2 Background The New Haven Wellness Information Network (WIN) was designed to improve access to care for uninsured patients utilizing the Yale New Haven Hospital Emergency Department. Provided case management services to link patients to primary care medical homes.

3 Background Emergency Departments (EDs) have seen enormous increases in visits, with more than one-half considered non-urgent. Although much of this increase is by insured patients, EDs are a major provider of care for the uninsured. ED care, compared to primary care is expensive, fragmented and lacking in basic preventive services.

4 Results Linkages led to: More primary care visits, Fewer hospitalizations, No change in ED use… Although ED visits became ‘less intense,’ Approximately break-even for the hospital.

5 Methods Design: Randomized Clinical Trial Shifts were randomly assigned to intervention or comparison. Timeframe: Recruitment for the evaluation took place between April 22, 2002 and July 21, Sample Size: 231 individuals 121 intervention, 110 comparisons.

6 ED Referral/Case Management Intervention On intervention shifts, patients who were uninsured, living in New Haven and without a primary health care provider were approached. Healthcare site chosen, Patient information faxed to the selected care site, Case Managers at the Primary Care Sites contacted participants and made appointments for case management assessments and/or medical care.

7 Analytic Design Consider all inpatient and ED visits within a six month-window after the initial ED visit. We omit data from the initial ED visit. In sensitivity analysis omit all care related to initial ED visit.

8 Economic Evaluation Provide evidence for sustainability from multiple perspectives: Hospital, Health Care System (including FQHCs), Societal.

9 Data Utilization data was provided by the primary care clinics and both New Haven hospitals Inpatient and outpatient costs assigned by a standardized, computerized, comprehensive cost assignment system including: Personnel, Laboratory, Specialty services, Room and board, and Other direct and indirect costs.

10 Intervention Comparison X 2 Sex: Male 82 (66.7%) 85 (77.3%) 2.60 (p=0.11) Female 39 (32.2%) 28 (22.7%) Age: < 30 years 62 (51.2%) 55 (50.0%) 3.27 (p=0.19) years 45 (37.2%) 49 (44.6%) > 50 years 14 (11.6%) 6 (5.5%) Race: White, not Hispanic 26 (22.6%) 21 (19.8%) 0.63 (p=0.72) Black, not Hispanic 43 (37.4%) 45 (42.5%) Hispanic (White or Black) 1 46 (40.2%) 40 (37.7%) Marital Status: Single 83 (69.5%)77 (71.3%)0.24 (p=0.95) Married 22 (18.6%) 19 (17.6%) Other 5 14 (11.9%)12 (11.1%) Results: Demographics for WIN Evaluation Participants.

11 No place to go 175 (76.1%) Knew ED would be open149 (64.8%) Would be seen without appointment139 (60.4%) No insurance 121 (52.6%) ED would give best care for problem 112 (48.7%) No transportation elsewhere 3 (1.3%) Refused care elsewhere 0 (0.0%) Results: Reasons for ED Visits.

12 Results: Utilization Outcomes InterventionComparisonp-value Case management and/or Medical Visit 51 % (62/121) 15 % (16/110) 34.7 (p<.01) Inpatient admissions0.8 % (1/121) 5.5 % (6/110) 4.2 (p=.04) ED visits37 % (45/121) 33 % (36/110).50 (p=.48)

13 Cost per ED visit InterventionComparison Pre - period $330 Post - period$245$312** Hypothesize differences are due to less intensity in ED visits for Intervention patients.

14 InterventionComparison ED costs$60$57 Inpatient costs$6$183** Hospital Costs (per Person)

15 Case Management Costs 2 months on project 3 case managers Annual salary + fringe = $ 57,375 /year 123 Intervention patients Cost of $233 per intervention patient

16 Results Benefits: $173 reduction in net hospital costs (per enrollee). Costs: $233 per person for case management (per enrollee).

17 Limitations Small data set Limited to one Northeastern urban location Questions about generalizability

18 Future Analyses Health related outcomes: Treatment for diabetes, hypertension, depression, Preventive care (e.g., advice on smoking, obesity). Societal perspective: Include costs of primary care visits, Include labor market outcomes, Include “quality of life” benefits.

19 Conclusion ED Referral/Case Management intervention can establish medical homes for uninsured individuals. Intervention is associated with lower hospital use. Although not cost saving, intervention clearly reduces hospital health care costs. Additional costs may be justified by improvements in health and productivity.