Payment review of emergency department eye care in Florida

A substantial proportion of emergency department eye care in Florida is reimbursed through Medicaid or paid for out of pocket by patients, and those findings may help in strategic planning as the debate over how best to implement the nation's new health care reform law progresses, according to a study published in the Archives of Ophthalmology, one of the JAMA/Archives journals.

The and Act (PPACA) will increase insurance coverage in large part by expanding eligibility for Medicaid, "an already stressed and underfunded system in many states," the authors explain in study background.

"Planning for such change in ophthalmology requires knowledge of what role Medicaid currently plays in the delivery of ," the authors suggest.

Matthew T. Witmer, M.D., the University of South Florida, Tampa, Fla., (now at New York- Presbyterian/Weill Cornell Medical Center) and colleagues analyzed Florida Agency for Health Care Administration emergency department data sets for outpatient visits and admissions for eye care from 2005 through 2009. A total of 587,227 emergency department visits were identified with a primary diagnosis in need of eye care and, of those visits, 12,105 resulted in . Researchers reviewed the types of insurance coverage reported and separated patients according to age as older or younger than 18 years.

During the five year study period, commercial insurance was the most frequent payer of emergency department outpatient services (31.1.percent), followed by self-pay (26.2 percent) and Medicaid (22 percent).

The results indicate that for patients under 18, Medicaid and self-payment accounted for 67.7 percent of principal payers. For outpatient emergency department visits, the percentage of change in Medicaid increased 5.9 percent for each calendar year and commercial coverage declined 4.5 percent.

The authors suggest that while their study cannot be "indiscriminately generalized" to other states, they believe the data are applicable to other states.

"Emergency department eye care will assume a larger safety-net function if more patients move into categories of Medicaid or self-pay. Already stressed EDs (emergency departments) and hospital staff need to be prepared to navigate change brought on by and the delayed economic recovery without compromising quality of care. Data within this study – although sobering – should be used for strategic planning as the debate on how to best implement PPACA moves forward," the authors conclude.

In an accompanying editorial, Paul Lee, M.D., J.D., and Jacqueline Dzau, M.D., M.P.H, of the Duke Eye Center, Duke University Medical Center, Durham, N.C., write, "The long-term growth in Medicaid, Medicare, and other public payor sources will only accelerate over the next 10 years, creating additional pressures and constraints on how we deliver eye care."

"To the extent that ED () payments are linked to an increasing proportion of patients, traditionally among the lowest paying of all payors for adult care, the economic incentive for ophthalmologists not employed by hospitals to provide coverage will decrease, further exacerbating challenges in obtaining call coverage of eye conditions," they write.

"If 'necessity is the mother of invention,' the findings described in the study by Witmer et al may be a harbinger of fundamental changes in the financing of ED provision of eye care and in the resulting care delivery models in Florida as well as the United States," Lee and Dzau conclude.

More information: Arch Ophthalmol. 2012;130[1]:25-32.
Arch Ophthalmol. 2012;130[1]:106-107.

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