title: An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs: financial and non-financial barriers have different associations.
abstract: BACKGROUND
  Emergency department (ED) use is costly, and especially frequent among publicly insured populations in the US, who also disproportionately encounter financial (cost/coverage-related) and non-financial/practical barriers to care. The present study examines the distinct associations financial and non-financial barriers to care have with patterns of ED use among a publicly insured population.
  
  
  METHODS
  This observational study uses linked administrative-survey data for enrollees of Minnesota Health Care Programs to examine patterns in ED use-specifically, enrollee self-report of the ED as usual source of care, and past-year count of 0, 1, or 2+ ED visits from administrative data. Main independent variables included a count of seven enrollee-reported financial concerns about healthcare costs and coverage, and a count of seven enrollee-reported non-financial, practical barriers to access (e.g., limited office hours, problems with childcare). Covariates included health, health care, and demographic measures.
  
  
  RESULTS
  In multivariate regression models, only financial concerns were positively associated with reporting ED as usual source of care, but only non-financial barriers were significantly associated with greater ED visits. Regression-adjusted values indicated notable differences in ED visits by number of non-financial barriers: zero non-financial barriers meant an adjusted 78% chance of having zero ED visits (95% C.I.: 70.5%-85.5%), 15.9% chance of 1(95% C.I.: 10.4%-21.3%), and 6.2% chance (95% C.I.: 3.5%-8.8%) of 2+ visits, whereas having all seven non-financial barriers meant a 48.2% adjusted chance of zero visits (95% C.I.: 30.9%-65.6%), 31.8% chance of 1 visit (95% C.I.: 24.2%-39.5%), and 20% chance (95% C.I.: 8.4%-31.6%) of 2+ visits.
  
  
  CONCLUSIONS
  Financial barriers were associated with identifying the ED as one's usual source of care but non-financial barriers were associated with actual ED visits. Outreach/literacy efforts may help reduce reliance on/perception of ED as usual source of care, whereas improved targeting/availability of covered services may help curb frequent actual visits, among publicly insured individuals.
authors: Division of Health Policy and Management, University of Minnesota, MMC 729, 420 Delaware Street SE, Minneapolis, MN 55455, USA. nshippee@umn.edu.
authors: Nathan D
authors: ND
authors: Shippee
authors: Tetyana P
authors: TP
authors: Shippee
authors: Erik P
authors: EP
authors: Hess
authors: Timothy J
authors: TJ
authors: Beebe
mesh_terms: D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data; D007348:Insurance, Health / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008910:Minnesota / Q000453:epidemiology; D013219:State Government