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. 2021 Aug 1;91(2):249-259.
doi: 10.1097/TA.0000000000003195.

Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage

Joshua D Jaramillo  1 , Katherine Arnow, Amber W Trickey, Katherine Dickerson, Todd H Wagner, Alex H S Harris, Linda D Tran, Sylvia Bereknyei, Arden M Morris, David A Spain, Lisa Marie Knowlton
Affiliations

Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage

Joshua D Jaramillo et al. J Trauma Acute Care Surg. .

Abstract

Introduction: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE.

Methods: We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed.

Results: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval.

Conclusion: The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention.

Level of evidence: Economic, level IV.

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References

    1. American Association for the Surgery of Trauma. The cost of injury. Published 2016. Available at: https://www.aast.org/resources/trauma-facts . Accessed September 27, 2019.
    1. Rajasingh CM, Weiser TG, Knowlton LM, Tennakoon L, Spain DA, Staudenmayer KL. Trauma-induced insurance instability: variation in insurance coverage for patients who experience readmission after injury. J Trauma Acute Care Surg . 2018;84(6):876–884.
    1. Haider AH, Weygandt PL, Bentley JM, Monn MF, Rehman KA, Zarzaur BL, Crandall ML, Cornwell EE, Cooper LA. Disparities in trauma care and outcomes in the United States: a systematic review and meta-analysis. J Trauma Acute Care Surg . 2013;74(5):1195–1205.
    1. Zogg CK, Payro Chew F, Scott JW, et al. Implications of the patient protection and affordable care act on insurance coverage and rehabilitation use among young adult trauma patients. JAMA Surg . 2016;151(12):e163609.
    1. Knowlton LM, Morris AM, Tennakoon L, Spain DA, Staudenmayer KL. Financial stability of level I trauma centers within safety-net hospitals. J Am Coll Surg . 2018;227(2):172–180.

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