Datapoints: Payer Source for Emergency Room Visits by Persons With Psychiatric Disorders

Emergency services are an important source of care for persons with psychiatric disorders. Use of emergency services is common among persons who do not have a usual source of care, including those without insurance. For these patients, such treatment is a poor substitute for ongoing care from outpatient providers in the community.

Data from the National Hospital Ambulatory Medical Care Surveys (1) were used to examine trends in emergency department care between 1993 and 1999. The surveys include a nationally representative multistage probability sample of visits to emergency departments in nonfederal short-stay hospitals. The data reported here are for persons aged 18 years or older who had a primary diagnosis of a mental illness (ICD-9 codes 290 to 319).

The number of visits to emergency departments increased by about 20 percent for this group over the seven-year period, from 2.22 million to 2.66 million visits (z=3.18, p<.01). The rate of visits also grew significantly, from 1,162 to 1,314 per 100,000 population (z=2.42, p<.02). As shown in Figure 1, the increase was greatest for patients without insurance, for whom the number of visits grew by about 63 percent (z=5.76, p<.01). In 1999 about 25 percent of visits to the emergency department by adults with a primary mental illness were not covered by insurance, compared with 19 percent in 1993. In contrast, the proportion of general medical visits that were not covered by insurance increased from 15 percent in 1993 to 18 percent in 1999. The number of visits for patients with a primary mental illness that were paid for through private, public (Medicare or Medicaid), or other insurance sources—for example, other state programs—did not significantly change over the study period.

The substantial increase in the number of visits to the emergency department by patients without insurance may reflect several recent trends in health care. Nationally, spending for mental health services has declined as a proportion of all health expenditures, and employers are reducing their mental health care costs (2). The more rigorous management of behavioral health care compared with general medical care may contribute to the rise in unreimbursed emergency department visits by persons with mental illness. Finally, national data indicate that persons with severe mental disorders are more likely to be uninsured (3).

Acknowledgment

This work was funded by the Robert Wood Johnson Foundation as part of Healthcare for Communities: The Alcohol, Drug, and Mental Illness Tracking Study.

Dr. McAlpine is affiliated with the division of health services research and policy in the School of Public Health at the University of Minnesota, 420 Delaware Street, S.E, Box 729 Mayo, Minneapolis, Minnesota 55455 (e-mail, [email protected]). Dr. Mechanic is with the Institute for Health, Health Care Policy, and Aging Research at Rutgers University in New Brunswick, New Jersey. Harold A. Pincus, M.D., and Terri L. Tanielian, M.A., are editors of this column.