1. Cost-sharing for Emergency Care and Unfavorable Clinical Events: Findings from the Safety And Financial Ramifications of ED Copayments (SAFE) Study AcademyHealth Annual Conference 7 June 2004

2. SAFE Study Team Joseph P. Newhouse, PhD Maggie Price, MA Richard Brand, PhD Tom Ray, MBA Bruce Fireman, MA Joseph V. Selby, MD, MPH John Hsu, MD, MBA, MSCE Harvard University Kaiser Foundation Research Institute University of California, San Francisco Funding Support: Agency for Healthcare Research and Quality No other relevant financial relationships to disclose

3. Background Health Care Costs Are Increasing Each Year Millions of Americans Face Increasing Levels of Cost-sharing –Both Higher Levels and Differential/Tiered Copays –A Common Practice Is Higher ED Copays Clinical Impact of Higher Cost-Sharing for Emergency Services Is Unclear, Especially in Managed Care Environment

4. Cost-Sharing Evidence Important to Establish Outcome Effects –No Insurance (Full Cost to Patient) Is Associated With Decreased Use of Medical Care and Worse Clinical Outcomes –RAND HIE Showed ED Cost-sharing (Partial Cost to Patient) Is Associated With a Reduction in Use of Emergency Care in General Population; No Apparent Outcome Effect –Entire ED Effect Within Lacerations on Non-Sutured Lacerations Comparison with the RAND HIE Results –Cost-Sharing the Same for ED and Office Visits –Did Not Sample Among Elderly –Did Not Study Cost Sharing In Managed Care Settings –Small Sample Meant Did Not Establish Effect on Mortality

5. Objective To Investigate the Impact of Cost-sharing for Emergency Care on Emergency Department (ED) Visits, Deaths, Hospitalizations, and ICU Admissions

6. Methods Design: Quasi-experimental Study with Concurrent Controls (Diff-in-Diff) Natural Experiment: Increase in ED Copayment Levels for Over Half the Population Population: –2,257,445 Patients with Commercial Insurance –261,091 Patients with Medicare Insurance Setting: Prepaid, Integrated Delivery System Time Period: 1999 - 2001 Excluded: Patients With Medicaid

7. Cost-Sharing Levels Commercial Insurance: –Free Care: No Cost-sharing for ED care –$1 – 5 Copayments –$10 –15 Copayments –$20 – 35 Copayments –$50+ Copayments Medicare Insurance: –Free Care: No Cost-sharing for ED care –$1 – 15 Copayments –$20+ Copayments There were no copayments other than the listed amounts during the study period.

8. Statistical Analysis Poisson Random Effects Model Propensity Score for Covariates: Age, Gender, Comorbidity (DxCG-based), Prior Utilization, SES (2000 US Census- based), Having a Regular Provider, Pharmacy Copayments, Medical Center Adjusted for Year and Month

9. Clinical Events ED Visits: In-system and Out-of-system –All ED Visits Hospitalizations: In-system and Out-of-system –All Non-elective Hospitalizations –In-system Hospitalizations with ICU Admissions Deaths: In-system and Out-of-system –All-cause Mortality

10. Results 2,257,445 Subjects With Commercial Insurance in 1999 –61% experienced increased cost-sharing during the study –52% experienced increased cost-sharing in 2000 –21% experienced increased cost-sharing in 2001 261,091 Subjects With Medicare Insurance in 1999 –68% experienced increased cost-sharing during the study –60% experienced increased cost-sharing in 2000 –13% experienced increased cost-sharing in 2001 Mean ED Visits: –18.4 Visits Per 100 Person-years (Commercial) –52.0 Visits Per 100 Person-years (Medicare) Mean Hospitalizations: –2.4 Hospitalizations Per 100 Person-years (Commercial) –17.9 Hospitalizations Per 100 Person-years (Medicare)

11. Changes in ED Copayment Levels: Commercially Insured Subjects (1999-2001)

12. Changes in ED Copayment Levels: Medicare Insured Subjects (1999-2001)

13. Baseline Characteristics: Commercial n(%) Total2,257,445(100) Age <15yrs480,188(21.3) 15-17yrs111,607(4.9) 18-29yrs375,413(16.6) 30-39yrs394,481(17.5) 40-49yrs413,975(18.3) 50-64yrs433,680(19.2) 65-74yrs36,106(1.6) 75-84yrs10,022(0.4) 85+yrs1,973(0.1) Female1,146,478(50.8) Low SES Neighborhood508,861(22.5) n(%) Chronic Disease Status in 1998 Asthma211,684(9.4) Diabetes69,065(3.1) Heart Failure6,936(0.3) Coronary Artery Disease25,194(1.1) Hypertension177,524(7.9) ED Visits in 1998 No Visits 1,947,136 (86.3) Office Visits in 1998 No Visits555,516(24.6) Hospitalizations in 1998 No Hospitalizations 2,222,704 (98.5) Drug Cost-sharing $0-$5 Copayments 1,536,891 (68.1) $7-$15 Copayments556,085(24.6) Co-insurance164,469(7.3)

14. Baseline Characteristics: Medicare n(%) Total261,091(100) Age <15yrs26(0) 15-17yrs0(0) 18-29yrs298(0.1) 30-39yrs1,309(0.5) 40-49yrs2,646(1) 50-64yrs9,924(3.8) 65-74yrs142,447(54.6) 75-84yrs85,074(32.6) 85+yrs19,367(7.4) Female145,810(55.8) Low SES Neighborhood49,251(18.9) n(%) Chronic Disease Status in 1998 Asthma24,646(9.4) Diabetes35,750(13.7) Heart Failure14,380(5.5) Coronary Artery Disease36,600(14) Hypertension118,204(45.3) ED Visits in 1998 No Visits194,327(74.4) Office Visits in 1998 No Visits22,146(8.5) Hospitalizations in 1998 No Hospitalizations237,142(90.8) Drug Cost-sharing $0-$5 Copayments119,672(45.8) $7-$15 Copayments130,166(49.9) Co-insurance11,253(4.3)

15. Unadjusted Rates of Clinical Events by ED Copayment Level Across All Years (1999-2001) Commercial Insurance Population

16. Unadjusted Rates of Clinical Events by ED Copayment Level Across All Years (1999-2001) Medicare Insurance Population

17. Adjusted Relative Rates of Clinical Events by ED Copayment Level: Commercial Insurance Population

18. Adjusted Relative Rates of Clinical Events by ED Copayment Level: Medicare Insurance Population

19. Adjusted Relative Rates of Clinical Events by ED Copayment Level in Subjects Living in Low SES Neighborhoods*: Commercial Insurance Population

20. Adjusted Relative Rates of Clinical Events by ED Copayment Level in Subjects Living in Low SES Neighborhoods*: Medicare Insurance Population

21. Conclusions In This Population of Patients in a Prepaid, Integrated Delivery System: Having to Pay a Portion of ED Costs Reduced ED visits, and by Roughly the Same Amount as in the RAND HIE There was No Evidence of Clinical Harm Associated with Having to Pay Higher ED Costs, i.e. Higher Cost-Sharing Did Not Result in More Hospitalizations or Deaths.

22. Limitations Range of ED Cost-sharing Levels: Free Care to $100 Copayments Per Visit –But Copays Above $100 per Visit Are Rare No Measures of Patient Awareness –May Have Understated Steady State Effects Single Integrated Delivery System

23. Implications Moderate Levels of Cost-Sharing for Emergency Services Appear Save Money With No Evidence of Adverse Effects