Medicaid Nursing Home Policies and Risk-Adjusted Rates of Emergency Department Visits: Does Rural Location Matter?

Objectives: Medicaid nursing home (NH) reimbursement rates and bed-hold policies have been shown to be associated with hospitalization of urban NH residents, but their relationships with emergency department (ED) visits, especially in rural NHs, remain unknown. This study explores the relationships of Medicaid NH policies with three NH quarterly risk-adjusted rates of ED use for long-stay residents and evaluates whether the associations differed by NHs' geographical locations. Design: Longitudinal study of Medicaid policies and NH risk-adjusted rates over 3 quarters (2011 Q3, 2012 Q3, and 2013 Q3), using Generalized Estimating Equation (GEE) models. Setting and Participants: 14,514 unique NHs. Measures: Quarterly risk-adjusted rates of any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) were calculated from national Medicare claims and NH Minimum Data Set 3.0. Medicaid policies were consolidated from several publicly available sources. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and the Area Health Resources File. Results: In 2012, states reimbursed NHs, on average, $162.60 per resident-day, and 36 states employed bed-hold policies. Although a $10 increase in reimbursement rates was associated with statistically significantly lower rates of any ED, outpatient ED, and PAED in both urban and micropolitan NHs (−0.79%, −1.09%, and −1.02% for urban NHs; −1.29%, −1.90%, and −3.22% for micropolitan NHs, respectively), it was not associated with any ED measure in rural NHs. Medicaid bed-hold polices were associated with about 9% to 12% lower rates of all types of ED visits in urban NHs, but were not related to any of the ED measures in micropolitan and rural NHs. Conclusions and Implications: Associations of Medicaid NH policies with ED utilization are weaker in rural NHs than urban NHs. Yet, the financial viability of increasing Medicaid reimbursement to reduce the ED use may not be cost-effective.