Variation in outpatient emergency department utilization in Texas Medicaid: a state-level framework for finding "superutilizers"

Background: Very frequent outpatient emergency department (ED) use-so called "superutilization"-at the state level is not well-studied. To address this gap, we examined frequent ED utilization in the largest state Medicaid population to date.

Methods: Using Texas Medicaid (the third largest in the USA) claims data, we examined the variability in expenditures, sociodemographics, comorbidities, and persistence across seven levels of ED utilization/year (i.e., 1, 2, 3-4, 5-6, 7-9, 10-14, and ≥ 15 visits). We classified visits into emergent and non-emergent categories using the most recent New York University algorithm.

Results: Thirty-one percent (n = 346,651) of Texas Medicaid adult enrollees visited the ED at least once in 2014. Enrollees with ≥ 3 ED visits accounted for 8.5% of all adult patients, 60.4% of the total ED visits, and 62.1% of the total ED expenditures. Extremely frequent ED users (≥ 10 ED visits) represented < 1% of all users but accounted for 15.5% of all ED visits and 17.4% of the total ED costs. The proportions of ED visits classified as non-emergent or emergent, but primary care treatable varied little as ED visits increased. Overall, approximately 13% of ED visits were considered not preventable or avoidable.

Conclusions: The Texas Medicaid population has a substantial burden of chronic disease with only modest increases in substance use and mental health diagnoses as annual visits increase. Understanding the characteristics that lead to frequent ED use is vital to developing strategies and Medicaid policy to reduce high utilization.