American Journal of Emergency Medicine (2009) 27, 1104–1108
ED use of military beneficiaries☆,☆☆ Robert A. De Lorenzo MD ⁎ Department of Clinical Investigations, Brooke Army Medical Center, Ft Sam Houston, TX 78234-6200, USA Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814-4799, USA Received 14 July 2008; accepted 9 August 2008
Abstract Context: The United States and Canada have ED use rates of approximately 40 visits per 100 population. Although the military network of hospitals shares many features with the civilian sector, this “system within a system” has universal health insurance coverage and provides an opportunity for comparison. Objective: The purpose of the study was to describe the emergency department (ED) use rate of a population of fully insured military health care beneficiaries. Design: A nonconcurrent database analysis of billing and visit data was performed to establish the ED use rate of military beneficiaries. Setting: The study operated within a global military health care system. Patients: The study involved military beneficiaries presenting to military and civilian EDs. Main Outcomes: The number of ED visits, demographics, and final diagnostic categories were analyzed. Descriptive methods were used to report data from fiscal years 2002 to 2007. Results: The military beneficiary population averaged 9.1 million persons during 2002 to 2007, and the corresponding ED use rate was 40.0 visits per 100 beneficiaries. There was an upward trend with the rate peaking in 2007 at 47.0. The number of military EDs declined from 76 in 2002 to 53 in 2007, whereas the average annual ED volume increased. The 95% confidence intervals are within ± 0.02% for all reported values. Conclusion: The ED use rate was 40 visits per 100 military health care beneficiaries from 2002 to 2007. This is very similar to rates reported for US and Canadian populations. Near universal insurance coverage does not necessarily result in reduced ED use. Military EDs share the civilian sector challenges posed by steadily rising patient volumes. Published by Elsevier Inc.
1. Introduction ☆
Presented at the Annual Meeting, Society for Academic Emergency Medicine, Washington, DC, May 29 to June 1, 2008. ☆☆ The opinions or assertions are those of the author and do not necessarily reflect those of the Army Medical Department or the Department of Defense. ⁎ Department of Clinical Investigations, MCHE-CI, Brooke Army Medical Center, Ft Sam Houston, TX 78234-6200, USA. Tel.: +1 210 916 1006; fax: +1 210 916 2265. E-mail address: [email protected]
0735-6757/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.ajem.2008.08.012
Emergency department (ED) use rate is an important indicator of overcrowding and can reflect overall access to care [1,2]. Previous studies have identified important trends in US and Canadian ED use including rising rates and total number of visits. Recent information suggests that insured populations may contribute at least as much to ED use and overcrowding as the uninsured. Li et al  report on the Ontario (Canada) experience and note the annual rate of 39.7 visits per
ED use of military beneficiaries 100 population is nearly identical to the 39.9 rate of the United States. Despite similar use rates, they noted access to health insurance in Canada is essentially universal, compared to the nearly 14.8% (43.6 million) uninsured in the United States. Although insurance status and access to care is a national problem, it is not evenly distributed among all communities. The US military operates a network of hospitals within the United States and abroad. Although sharing many features with the civilian sector, the military health care system is largely separate—it has its own patient population, funding sources, insurance plans, facilities, doctors, and in many cases, its own geographic communities (eg, bases and posts). This separate health care “system within a system” permits a potential comparison of insurance status because all military beneficiaries are covered by the Tricare program or Medicare . This study aims to quantify the ED use rates for military beneficiaries and describe recent trends in use and annual ED volumes.
2. Methods 2.1. Study design A nonconcurrent database analysis of billing and visit data was performed to establish the ED use rate of military beneficiaries. The study met exempt criteria for regulatory review and was approved by the institutional review board in advance of its commencement.
2.2. Setting and population The US Military Health System (MHS) operates nearly 500 fixed facility hospitals and clinics in its worldwide network and has a health care budget exceeding $23 billion. In 2007, 9.2 million beneficiaries were eligible for care, including 1.4 million active duty service members and mobilized reservists, 1.8 million retirees, and 6 million family members. Recently wounded servicemembers are retained in the system through the initial rehabilitation phases; however, discharged veterans, unless they are retired, are generally ineligible for care in the MHS. Instead, the Veterans Health Administration is responsible for managing veterans' service-connected care. Beneficiaries can seek care at any of the MHS facilities or visit a civilian physician or hospital. The military health care program is called Tricare and has benefits that vary depending on the category of the beneficiary. Approximately 5.4 million beneficiaries are enrolled in the main managed care programs that offer low or no out-of-pocket expenses. More than 1.6 million beneficiaries are retirees older than 65 years and are dually enrolled in Tricare and Medicare. For most enrolled beneficiaries, emergency care is provided at no cost in military EDs and is available in civilian EDs at either no cost in networked hospitals or with modest cost shares. Almost 2.2 million beneficiaries are not enrolled in a Tricare-
1105 managed care plan but are still eligible to receive care at military hospitals at no cost or visit civilian EDs, typically with an annual deductible of $50 to $150.
2.3. Protocol and measurements The overall study design is a nonconcurrent (retrospective) database review. The number of ED visits by military beneficiaries at either military or civilian hospitals was extracted from the MHS Management Analysis and Reporting (M2) tool. M2 is a component of the MHS Executive Information and Decision Support suite of database applications that includes demographics, abstracted clinical information, and billing codes for the entire military beneficiary population. This includes all visits in a military ED and all visits in a civilian ED by a beneficiary who files a claim. Visits to a fast-track or urgent care centers were included if they are associated with and adjacent to the main ED. Separate clinics, even if on the same campus, were excluded. Permanent overseas facilities were included, whereas deployed hospital EDs, such as those in Iraq and Afghanistan, were not included. Sex, age group, and final diagnostic categories were included in the analysis. Because the database was designed primarily for billing and health care business applications, the data for encounters in a military ED is handled differently than for encounters occurring in a civilian ED. The former are tracked as discrete visits, whereas the latter are organized into insurance claims that must be grouped into an associated patient visit (one visit usually generates one claim, but occasionally ≥2 claims reflect a single visit). A sampling of 27 000 claims was analyzed to establish a ratio of claims-to-visit and used to adjust the civilian ED data. Claims with the same visit date and ED location were assumed to be a single ED visit.
2.4. Primary data analysis The military beneficiary population for each year of interest was extracted from M2 and serves as the denominator for calculating use rates (number of annual ED visits per 100 beneficiaries). Overall beneficiary demographics
Table 1 Military beneficiaries by age and corresponding ED visit rates (fiscal years 2002-2007) Age Military beneficiaries, Mean no. of annual ED visits group in millions (%) per 100 beneficiaries 0-14 15-24 25-44 45-64 65-74 75+ Total
1.44 (15.7) 1.53 (16.8) 1.88 (20.6) 1.87 (20.5) 1.62 (17.7) 0.79 (8.6) 9.14 (100)
51.54 47.50 42.78 27.39 24.50 53.72
R.A. De Lorenzo
Fig. 1 Military beneficiary ED use rates, fiscal years 2002 to 2007. Shaded portion represent visits at military EDs; unshaded portion represents visits at civilian EDs.
including age and sex distribution were also retrieved. Discharge diagnoses are grouped into major categories according to the International Classification of Diseases, Ninth Revision, Clinical Modification. The number of military EDs and visits in each year were used to calculate average annual ED volumes. Data from 2002 to the 2007 were evaluated with all reported years defined by fiscal year (October 1 of the preceding calendar year to September 30). Annual means are calculated as simple arithmetic means for data in each fiscal year, whereas means reported for the entire period are calculated from all sample points. Descriptive statistics were used for data presentation with 95% confidence intervals calculated for all primary analyses.
3. Results The military beneficiary population averaged 9.1 million persons (range, 8.7-9.2 million) during the period
2002 to 2007. Males comprised 51.8% of the beneficiaries, and persons 25 to 44 years comprised the largest age group (Table 1). During the same period, there were an average of 1.6 million military ED visits and 2.0 million beneficiary visits to civilian EDs identified each year. The average ED use rate for the period is 40.0 visits per 100 beneficiaries (Fig. 1). There was a generally upward trend during the period with the rate peaking at 47.0 visits per 100 beneficiaries in 2007. People aged 75 and older had the highest ED visit rate and people aged 65 to 74 the lowest (Table 1). Women comprised a higher percentage of ED visits than men— 59.9% vs 40.1%. The top 3 diagnostic categories were injury and poisonings (21.7%), signs and symptoms (16.8%), and respiratory diseases (15.3%). Confidence intervals are within ± 0.02% for all reported values. The number of military EDs declined from 76 in 2002 to 53 in 2007, whereas the average annual ED volume showed an upward trend (Fig. 2).
Fig. 2 Annual patient volumes and number of military EDs, fiscal years 2002 to 2007. Bars represent military ED volumes per year. Diamonds represent number of military EDs.
ED use of military beneficiaries
4. Discussion The 2003 US military beneficiary ED use rate of 34.3 visits per 100 population is slightly lower than that reported for civilian US (39.9) and Ontario, Canada (39.7) . The average military beneficiary rate from 2002 to 2007 (40.0) is highly consistent with rates reported for the US population . Likewise, the top 3 diagnostic categories are the same in the military and civilian populations, although the exact percentages differ slightly . These similarities are remarkable considering the differing demographics, health status, and insurance rates of US military beneficiaries and the US and Ontario populations as a whole; military beneficiaries are in general younger and, in contrast to the general US population, are fully insured [4,5]. Differences become apparent when the use rates of different age groups and sex are examined. In the military beneficiary population, the younger age groups tend to dominate (Table), and the oldest age groups (65-74 and ≥75 years) show rates less than the general US and Ontario experience . Female military beneficiaries appear to use the ED at a rate greater than their proportion of the beneficiary population. The reasons for the differences are unclear but may be related to the generally better health status of older military beneficiaries as well as decreased access to primary care for younger beneficiaries. A factor potentially explaining the sex disparity is the ED visits of deployed servicemembers, most of whom are male, is not recorded in this study. Fig. 1 shows an increasing overall use rate that can be attributed to increases in the use of civilian EDs. Contributions to this increase may include a rising population as the number of military beneficiaries increased by approximately 7% since 2002. By comparison, military ED patient volumes have remained largely unchanged over the period studied. The reasons for this are unclear but may include a beneficiary preference for civilian EDs or a lack of military ED capacity to absorb more patients. Other reasons for these trends, including access to primary care, were not examined. Recovering casualties from the war in Iraq and Afghanistan were not specifically analyzed; their contribution to ED use rates is likely proportional to the approximately 13 800 serious casualties accumulated during the study period. Because of a steady decline in the number of military EDs, there is a corresponding rise in average ED census (Fig. 2). In 1988, the military had 164 EDs, but by the turn of the century, this number was cut in half . Military ED closure has accelerated in recent years with more closures planned . The civilian sector, too, has seen the closure of EDs and has also experienced an increase in demand [2,8]. Until recently, the prevailing view was that high rates of insurance lead to lower ED use, presumably because of better access to primary care. This study lends important support for the contention that insurance status has limited impact on ED use. With rare exceptions, all users of military EDs are covered by one or more federal government health insurance programs including Tricare and Medicare, yet use rates are similar to the general US population.
1107 Previous studies have also shown that populations with universal insurance coverage tend to use the ED at rates similar to more heterogeneously insured populations. In 2003, Cunningham and May  provided evidence showing that the rising tide of uninsured Americans is not the major factor involved in ED overcrowding. Weber et al  found that health status was a more important determinant of ED use than insurance status. Li et al  showed that the universal coverage of Ontario (Canada) residents is nearly identical to US residents who have varying coverage. Thus, high rate of insurance does not necessarily equate to lowered ED use rates. The health policy implications are significant because ED use may be linked to overcrowding . Because of their critical nature and availability to all populations, EDs are often considered the nation's health care “safety net,” and access to emergency care may hint at overall health care system function [2,3,8,11]. Current published evidence of military ED overcrowding is incomplete. The American College of Emergency Physicians, as part of a “report card” on the status of the nation's emergency care system, noted: “In recent years, there have been dramatic increases in patient volume and subsequent overcrowding at some military hospitals: there are several reasons for this, including the increased crowding in all EDs…and the increase of the beneficiary population… Cost saving measures during the past several years to close several smaller military hospitals and EDs has resulted in decreased access to emergency care for selected base and post populations .” A recent lay press account underscores the observation of decreased access, suggesting the problems are widespread . The results of this study should be interpreted in light of the population-level design. Only associations between insurance status and use, not direct causal relationships, can be established using these results. Because data were derived from a billing and health care management database, it is an indirect measure of an ED visit. The database is generally populated with extracts of the medical record and, in the case of civilian ED visits, is further routed through a billing and claims process. Transcription errors are possible, as are lost or duplicated records. It is also possible that some beneficiaries visiting civilian EDs may choose not to file a claim, although this is estimated to be uncommon because Tricare cost shares do not vary with a beneficiary's claim history. The data from the military EDs are likely more reliable than that derived from claims records because there are numerous internal system checks in place. It is also possible that some visits counted in military EDs are from nonmilitary beneficiaries (eg, reserve officers' training corps cadets, foreign military, and civilian emergencies) and thus outside the population of interest. However, review of data from 2006 indicates such visits account for less than 1.5% of the military ED total. In addition, the military beneficiary population is not static as servicemembers join and leave the military, although by examining 6 consecutive years, this latter limitation is mitigated. Importantly, the database used in this study is different than
1108 those used by Li et al  to describe the general US and Ontario health care systems, potentially limiting comparisons. The universal insurance coverage of military beneficiaries must be qualified. Although all beneficiaries have coverage under Tricare or Medicare, the level of access to military facilities, cost sharing and fees, and other factors varies by the individual's enrollment status . Care in a military ED is generally at no cost to the beneficiary, but it is not always accessible, and patients must otherwise seek care in civilian EDs. In comparison to traditional private insurance, Tricare reimbursement is low and has been criticized as being on par with Medicaid, the insurance program for the poor . Nevertheless, the military has a well-established patient bill of rights that codifies the prudent layperson standard for emergency care access .
5. Conclusion The ED use rate is 40 visits per 100 military health care beneficiaries and is very similar to rates reported for US and Canadian populations. Near universal insurance coverage in this population does not necessarily result in reduced ED use. Military EDs may share with the civilian sector the challenges posed by steadily rising volumes and overcrowding. Future studies should explore the factors involved in ED use with an eye toward developing models that can be applied across many settings.
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