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Obstetrical Complications Account for Major Emergency Medicaid Spending


CHAPEL Hill, N.C. -- Childbirth and pregnancy complications were responsible for the major part of emergency Medicaid spending for undocumented and recent immigrants in North Carolina, according to a study.

CHAPEL Hill, N.C., March 13 -- Childbirth and pregnancy complications were responsible for the major part of emergency Medicaid services spending for undocumented and recent immigrants in North Carolina, researchers reported.

In addition, spending for undocumented elderly and disabled patients is increasing at a faster rate, according to a study in the March 14 issue of the Journal of the American Medical Association, a theme issue on access to care.

Finally, injury, other acute emergencies, and severe complications of chronic disease, were major contributors to the use of emergency Medicaid, said C. Annette DuBard, M.D., of the University of North Carolina here and co-author Mark Massing, M.D., Ph.D., of the Carolinas Center for Medical Excellence in Cary, N.C.

"Medicaid spending for emergency care of recent and undocumented immigrants, although a small proportion of the total Medicaid budget, is increasing rapidly in this new immigrant growth state," they wrote.

Federal law generally excludes undocumented immigrants, as well as legal immigrants in the U.S. for less than five years, from Medicaid eligibility. They can receive Medicaid coverage for emergency medical services if they are in a Medicaid-eligible category, such as children, pregnant women, families with dependent children, elderly or disabled individuals and meet residence and income requirements, the researchers wrote.

Undocumented immigrants make up an increasing proportion of newly arrived individuals, estimated at 29% of the total U.S. foreign-born population, said Drs. DuBard and Massing.

The findings emerged from an analysis of administrative data related to all claims reimbursed under emergency Medicaid eligibility criteria from 2001 through 2004 in North Carolina.

A total of 48,391 individuals received services reimbursed under emergency Medicaid during the four-years of the study. The patient population was 99% undocumented, 93% Hispanic, 95% female, and 89% ages 18 to 40. Of the women, 90% were eligible due to pregnancy.

Total spending increased by 28% from 2001 through 2004, with more rapid spending increases among the elderly and disabled patients.

In 2004, childbirth and complications of pregnancy accounted for 82% of spending and 91% of hospitalizations.

Spending increased by 22% for pregnant women during the four-year period, by 20% for children, by 70% for families with dependent children, compared with 82% for disabled patients and 98% for elderly patients, the researchers reported.

Most of the increase in spending was pinned to growth in the number of nonpregnant patients served. There were substantial increases among disabled and elderly patients. In 2004, median expenditures were considerably higher for disabled patients (,050) than for elderly patients (,603), pregnant women (,993), families (,774), or children (,413).

Injury, renal failure, gastrointestinal disease, and cardiovascular conditions were also prevalent. Injury and poisoning accounted for approximately a third of the remaining spending, largely due to intracranial injuries, fractures, and crushing or internal injuries.

The high rate of workplace injuries and fatalities accounting for one-third of all emergency Medicaid spending in this study indicates a "dire need" for injury prevention interventions that target the new immigrant populations, especially Hispanics.

Other prominent diagnostic categories were diseases of the digestive system (16% of spending outside of pregnancy), genitourinary system (12%), and circulatory system (11%), as well as neoplasms (6%).

The findings from this study shed light on a previously unstudied subject, but they relate only to Medicaid coverage of emergency medical conditions, Drs. DuBard and Massing wrote in discussing the study's limitations. The findings do not reflect non-emergency care or care provided for immigrants with work coverage, or emergency care for immigrants who do not meet Medicaid category and income requirements.

Furthermore, race/ethnicity and immigration status were provided by social services throughout the state, and coding accuracy could not be assessed for these measures.

Finally, they said, policies regarding state funding of health care for immigrants are quite variable throughout the nation. The trends shown here provide important insights into the health-care needs of immigrants in new-growth states, and reveal the limited scope of services available under current federal law.

These findings from the North Carolina study, the investigators said, are most applicable to states experiencing high rates of new immigration from Mexico and Latin America.

Emergency Medicaid is predominantly a program for childbirth coverage, although use and spending are shifting toward nonpregnant adults, particularly those who are elderly and disabled, they said.

"Increased access to comprehensive contraceptive and prenatal care, injury prevention initiatives, preventive care, and chronic disease management may make better use of the public health care dollar by improving the health status of this population and alleviating demand for costly emergency care," they concluded.

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