Implications for Emergency Department Utilization Among Medicaid Beneficiaries
Open Access DepositedSocial Risk, Chronic Illness Burden, and Continuity of Care
Medicaid beneficiaries face disproportionately high social risk and chronic illness burden, which contribute to costly, fragmented care and inequities in access, quality, and health outcomes. In the District of Columbia (D.C.), nearly all Medicaid beneficiaries are enrolled in managed care plans, yet many rely on the emergency department (ED) for care, which is a signal of fragmented or inadequate access. Continuity of care (COC), the extent to which patients experience their care as connected and coherent, is associated with high-quality, cost-effective primary care and reduced ED utilization. Strengthening COC may offer a modifiable pathway to reduce avoidable ED utilization among Medicaid beneficiaries with social and clinical complexity. Using a post hoc secondary analysis of linked Medicaid claims and social determinants of health survey data on adult D.C. Medicaid beneficiaries, this dissertation examines the following questions across three papers
(1) What is the relationship between individual-level social risk and COC? (2) What is the relationship between COC and ED use? (3) Does the effect of COC on ED use vary by chronic illness burden? Greater social risk was associated with lower COC at the practice level but higher COC at the provider level, with both associations most pronounced for individuals in the highest risk classes. Higher COC was associated with fewer ED visits, and this effect was stronger and more consistent at the practice level. Interaction analyses indicated that the protective effect of COC on ED use was greatest among individuals with high chronic illness burden, particularly those also experiencing high social risk. These studies add to the literature by empirically linking social risk, chronic illness burden, COC, and ED use in one analytical framework, and addressing gaps in prior work by evaluating individual-level social risk, multiple COC levels, and interaction effects among Medicaid beneficiaries in a longitudinal design. Findings suggest that COC is a modifiable mechanism in the health system through which social and chronic illness burden may contribute to inequities in ED use. Policies that strengthen COC, particularly at the practice level, and address upstream structural barriers may reduce preventable ED use among patients with complex needs.
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