Health affairs
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Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. ⋯ Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.
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Considerable attention is being paid to hospital readmission as a marker of poor postdischarge care coordination. However, little is known about another potential marker: emergency department (ED) use. We examined ED visits for Medicare patients within thirty days of discharge for six common inpatient surgeries. ⋯ There was substantial variation-as much as fourfold-in hospital-level ED use for these patients across all six procedures. The variation might signify a failure in upstream coordination of care and therefore might represent a novel hospital quality indicator. In addition, the postdischarge ED visit is an opportunity to ensure that care is properly coordinated and is the last best chance to avoid preventable readmissions.
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Homeless adults may gain access to health services under the Affordable Care Act's Medicaid expansion, which takes effect in 2014. This study analyzed the health coverage, health status, and health services use of 725 chronically homeless adults with disabilities in eleven cities in the United States. Nearly three-quarters of the chronically homeless adults in this study with incomes below the threshold for the Medicaid expansion were not enrolled in Medicaid. ⋯ There may be potential savings for states that expand Medicaid, as people transition from state and local assistance to more comprehensive services under Medicaid. Targeted outreach and assistance to enroll eligible homeless people will be necessary. A broad range of physical and mental health services will be required, including case management to coordinate services.
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The Affordable Care Act will expand insurance coverage to more than twenty-five million Americans, partly through subsidized private insurance available from newly created health insurance exchanges for people with incomes of 133-400 percent of the federal poverty level. The act will alter the financial incentive structure for employers and influence their decisions on whether or not to offer their employees coverage. These decisions, in turn, will affect federal outlays and revenues through several mechanisms. ⋯ We assess revenues and subsidy outlays for premiums and cost sharing for individuals purchasing private insurance through exchanges. Our findings show that changing theoretical premium contribution levels by just $100 could induce 2.25 million individuals to transition to exchanges and increase federal outlays by $6.7 billion. Policy makers and analysts should pay especially careful attention to participation rates as the act's implementation continues.