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The American Journal of Managed Care March 2019
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Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
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Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries

Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Among Medicaid beneficiaries, having more fragmented ambulatory care was associated with a modest independent increase in the hazard of a subsequent emergency department visit.
ABSTRACT

Objectives: Results of previous studies of Medicare beneficiaries have shown that more fragmented ambulatory care is associated with more emergency department (ED) visits and hospital admissions. Whether this observation is generalizable to Medicaid beneficiaries is unknown.

Study Design: We conducted a 3-year retrospective cohort study in the 7-county Hudson Valley region of New York. We included 19,330 adult Medicaid beneficiaries who were continuously enrolled, were attributed to a primary care provider, and had 4 or more ambulatory visits in the baseline year.

Methods: We measured fragmentation using a modified Bice-Boxerman Index. Cox proportional hazards models were used to determine associations between fragmentation score and ED visits or, separately, hospital admissions, adjusting for age, gender, and chronic conditions.

Results: The average beneficiary had 15 ambulatory visits in the baseline year, spread across 5 providers, with the most frequently seen provider accounting for 48% of the visits. One-fourth of the sample had more than 20 ambulatory visits and more than 7 providers, with the most frequently seen provider accounting for fewer than 33% of visits. For every 0.1-point increase in fragmentation score, the adjusted hazard of an ED visit over 2 years of follow-up increased by 1.7% (95% CI, 0.5%-2.9%). Having more fragmented care was not associated with a change in the hazard of a hospital admission.

Conclusions: Among Medicaid beneficiaries, having more fragmented care was associated with a modest increase in the hazard of an ED visit, independent of chronic conditions. Fragmented ambulatory care may be modifiable and may represent a novel target for improvement.

Am J Manag Care. 2019;25(3):107-112
Takeaway Points

To determine any association between fragmented ambulatory care and subsequent healthcare utilization, this retrospective cohort study analyzed claims for 19,330 adult Medicaid beneficiaries.
  • For every 0.1-point increase in fragmentation score, the adjusted hazard of an emergency department (ED) visit over 2 years of follow-up increased by 1.7% (95% CI, 0.5%-2.9%). For every 71 patients with high fragmentation, there is a risk of 1 additional ED visit.
  • Having more fragmented care was not associated with a change in the hazard of a hospital admission.
  • Fragmented ambulatory care may be modifiable and may represent a novel target for improvement.
Having highly fragmented ambulatory care, which is care spread across multiple providers without a dominant provider, has been associated with higher rates of emergency department (ED) visits and hospital admissions among Medicare beneficiaries.1,2 When patients have fragmented care, it is often difficult for providers to communicate adequately with each other, and adverse events may follow.3,4 However, patterns observed in Medicare may not be generalizable to other populations.5

The goal of this study was to determine if more fragmented ambulatory care is independently associated with more ED visits and hospital admissions, compared with less fragmented care, among Medicaid beneficiaries. We specifically sought to explore this issue while teasing apart the pattern of ambulatory care from the number of chronic conditions, because having fragmented care may affect patients differently depending on how many chronic conditions they have.6

The issue of fragmentation has become increasingly important with the emergence of value-based purchasing, which requires that providers become newly responsible for all of a patient’s care, not just care that they themselves provide.7 In this context, understanding fragmentation and its consequences becomes essential for effective population health management. Thus, the rationale for this study is to generate data-driven insights that can inform the design of future interventions to improve care patterns and outcomes.

METHODS

Overview

We conducted a retrospective cohort study (2010-2012) of adult Medicaid beneficiaries who received care from physicians in the Hudson Valley region of New York to determine associations between fragmented ambulatory care and subsequent ED visits and hospital admissions. The Institutional Review Board of Weill Cornell Medicine approved the protocol.

Setting

The Hudson Valley region consists of 7 counties (Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester) immediately north of New York, New York. At the time of the study, most healthcare in the region was delivered by physicians in small- and medium-sized private practices, using fee-for-service (FFS) reimbursement from multiple payers.8

Data

We used Medicaid claims for 2010-2012, extracting the following claim-level variables: patient study identifier (ID), patient date of birth, patient gender, date of service, rendering provider ID, Current Procedural Terminology (CPT) codes, and International Classification of Diseases, Ninth Revision (ICD-9) codes. We also extracted monthly patient-level enrollment data. Claims were included for both FFS and managed care products, with the same level of detail for the claims regardless of business line.

Study Sample

We first identified primary care physicians (PCPs; general internists and family medicine physicians) in the claims who had billing zip codes in the Hudson Valley region. We determined which Medicaid beneficiaries 18 years and older could be attributed to those PCPs, based on 2010 claims, using previously defined attribution logic.9 Ambulatory visits were defined by CPT codes, using a modified version of the definition from the National Committee for Quality Assurance (NCQA).10 Modifications restricted the definition to evaluation and management visits for adults in an office setting, excluding management-only visits (eg, dialysis, chemotherapy, and physical therapy) and non–office-based visits (eg, home visits and visits in nursing facilities). This definition excluded ED visits.

We excluded those who were not continuously enrolled in the baseline year, and we excluded beneficiaries with outlier observations (>99.9th percentile) for number of visits or number of unique providers, as those observations may have been erroneous. Next, we restricted the cohort to those with 4 or more visits in the baseline year, because calculating fragmentation with fewer visits can lead to statistically unstable estimates.2 We required that beneficiaries be continuously enrolled in Medicaid for at least 1 more consecutive year, contributing data for 2 (2010-2011) or 3 (2010-2012) years. We excluded those who were in the hospital on January 1, 2011, because they were not at risk for an ED visit or hospital admission at the start of follow-up. We also excluded any beneficiary with a claim for pregnancy and/or labor and delivery during the follow-up period, because ED visits and hospitalizations for those patients are expected.


 
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