"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 c reated 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, Int ernational Classification of Diseases, Ninth Revision discharge diagnosis, insurance status, date of visit, time of visit, and ZIP code. Visits were c lassified as either urgent or nonurgent based on discharge diagnosis. Rates of ED use per 1000 persons were calculated using county population and Med icaid enrollment figures. Results: A total of 54742 ED visits occurred between January 1, 1995, and D ecember 31, 1997. Thirty-eight percent of these visits were by children (de fined as those aged 0-18 years in this study) enrolled in the Medicaid prog ram. After the implementation of CA, monthly ED rates per 1000 children wit h 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 Med icaid 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 ra tes 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 tempo ral relation between decreased visits to the ED and increased access to pri mary 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 availabil ity 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.