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Ambulatory Care: Emergency Department Visits

VISIT THE DOMAIN: Make Care Affordable

Unnecessary visits to a hospital emergency department (ED) may indicate lack of access to more appropriate sources of medical care, such as primary care providers or specialists. Excessive visits to the ED can result in overcrowding and increased ED wait times. Understanding the rate of ED visits among children covered by Medicaid and CHIP can help states identify strategies to improve access to and utilization of appropriate sources of care.

Explore the rate of ED visits per 1,000 beneficiary months for children ages 0 to 19. Lower rates are better.

The purple dashed line represents the median, or middle of all values reported.

This measure reports the rate of ED visits per 1,000 beneficiary months for children ages 0 to 19.

States voluntarily report on Ambulatory Care: Emergency Department Visits (AMB-CH) as part of the Core Set of Children's Health Care Quality Measures. These data show performance rates for states that voluntarily reported the measure using Child Core Set measure specifications.

The included populations and reporting methods for Child Core Set measures can vary by state. For example, some states report data on certain populations such as those covered under managed care but not those covered under fee-for-service (FFS). This variation in data can affect measure performance and comparisons between states.

Ambulatory Care: Emergency Department Visits

Legend explaining categories contained in the following graphic.

Ambulatory Care: Emergency Department (ED) Visits. Bar Graph with Median of 44.5, and the categories and values described in the table below.

State Population Rate per 1,000 beneficiary months
AK Medicaid & CHIP 35.7
AL Medicaid only 49.9
AR Medicaid & CHIP 44.2
AZ Medicaid only 39.3
CA Medicaid & CHIP 35.2
CT Medicaid & CHIP 50.0
DC Medicaid & CHIP 58.7
DE Medicaid & CHIP 48.9
FL Medicaid & CHIP 53.5
HI Medicaid & CHIP 36.3
IA Medicaid only 39.1
IL Medicaid & CHIP 45.9
IN Medicaid & CHIP 46.9
KS Medicaid & CHIP 48.0
KY Medicaid & CHIP 56.7
LA Medicaid & CHIP 57.0
MA Medicaid & CHIP 43.7
MD Medicaid & CHIP 38.8
ME Medicaid & CHIP 40.5
MI Medicaid only 53.2
MN Medicaid & CHIP 38.9
MO Medicaid & CHIP 60.0
MS CHIP only 37.9
MT CHIP only 21.0
NC Medicaid only 45.7
NE Medicaid & CHIP 37.5
NH Medicaid & CHIP 35.8
NJ Medicaid & CHIP 47.1
NM Medicaid & CHIP 35.8
NV Medicaid only 40.5
NY Medicaid & CHIP 36.4
OH Medicaid & CHIP 70.8
OK Medicaid & CHIP 65.8
OR Medicaid & CHIP 33.4
PA Medicaid & CHIP 49.8
RI Medicaid & CHIP 40.5
SC Medicaid & CHIP 44.8
TN Medicaid only 53.3
TX Medicaid only 48.9
UT Medicaid only 33.4
VT Medicaid & CHIP 37.4
WA Medicaid & CHIP 35.9
WV Medicaid only 54.0
WY Medicaid only 47.4

States reporting, 44. Median rate, 44.5 per 1,000 beneficiary months.

Source: Mathematica analysis of Medicaid and CHIP Program System (MACPro) reports as of June 3, 2019 for the Child Core Set Federal Fiscal Year (FFY) 2018 reporting cycle; see 2018 Child and Adult Health Care Quality Measures. For more information on Ambulatory Care: Emergency Department Visits (AMB-CH) visit Child Health Care Quality Measures.

Notes:

The following states did not report data to the Centers for Medicare & Medicaid Services (CMS) for this measure: CO, GA, ID, ND, SD, and WI.  

The following state used Child Core Set specifications to calculate the measure but did not provide data for the Total (Ages 0-19) rate: VA. CMS did not include the rate for this state.  

The Child Core Set specifications include guidance for calculating this measure using the administrative method.  Unless otherwise specified, the administrative data source is the state’s Medicaid Management Information System (MMIS) and/or data submitted by managed care plans, including behavioral health plans.

Unless otherwise specified:

  • States used Child Core Set specifications, based on National Committee for Quality Assurance (NCQA) 2018 specifications. The following state used NCQA 2017 specifications: OR.
  • Denominators are assumed to be the measure-eligible population for states using the administrative method. Some states reported exclusions from the denominator, as noted in the state-specific comments.
  • The measurement period for this measure was January 1, 2017 to December 31, 2017. AZ reported data for FFY 2016.

ADHD = Attention-Deficit/Hyperactivity Disorder; CCO = Coordinated Care Organization; CHIP = Children’s Health Insurance Program; CMS = Centers for Medicare & Medicaid Services; CPT = Current Procedural Terminology; CY = Calendar Year; ED = Emergency Department; EPSDT = Early and Periodic Screening, Diagnostic, and Treatment; EQRO = External Quality Review Organization; FFS = Fee for Service; FFY = Federal Fiscal Year; HEDIS = Healthcare Effectiveness Data and Information Set; HMO = Health Maintenance Organization; ICD = International Classification of Diseases; LOINC = Logical Observation Identifiers Names and Codes; MACPro = Medicaid and CHIP Program System; MCO = Managed Care Organization; MMIS = Medicaid Management Information System; NCQA = National Committee for Quality Assurance; NR = Not Reported; PCCM = Primary Care Case Management; PCP = Primary Care Practitioner.

State-Specific Comments follow below. Comments also contain the CHIP population rate for states that submitted it separately:

AL:          Medicaid rate includes FFS and PCCM populations. CHIP rate includes separate CHIP population. Rate excludes children enrolled in Medicaid-expansion CHIP; these children are included in the state's Medicaid rate. CHIP only rate: 27.5 per 1,000 beneficiary months.

AK:          Rate includes FFS population.

AZ:          Rate includes managed care population (7 MCOs), representing 92 percent of the population. Rate excludes FFS population, seriously mentally ill population, Children's Rehabilitative Services (CRS) population, and state long-term care elderly, physically, or developmentally disabled population, representing 8 percent of the population. State conducted an internal validation of the data.

AR:          Rate includes FFS and PCCM populations. State used the last day of the month to determine beneficiary months of enrollment. Rate was audited by the state's data contractor.       

CA:          Rate includes FFS and managed care populations (26 MCOs).

CT:          Rate includes FFS population. Rate was audited by a certified HEDIS auditor.

DE:          Rate includes managed care population (1 MCO), representing 86 percent of the population. Rate excludes FFS population and enrollees in one MCO, representing 14 percent of the population.

DC:         Rate includes managed care population (3 MCOs), representing 66 percent of the population. Rate excludes FFS population and one MCO, representing 34 percent of the population.  MCO rates were audited by certified HEDIS auditors.

FL:           Rate includes FFS, PCCM, and managed care populations (21 MCOs). MCO rates were audited by a certified HEDIS auditor.

HI:           Rate includes managed care population (5 MCOs). Rate was validated by the state's EQRO.

IL:            Rate includes FFS, PCCM, and managed care populations (13 MCOs). Rate was validated by the state's EQRO.

IN:           Rate includes managed care population (3 MCOs), representing more than 90 percent of the population. Rate excludes FFS population, representing less than 10 percent of the population. MCO rates were audited by certified HEDIS auditors.

IA:           Mediate includes FFS and managed care populations (3 MCOs). CHIP rate includes managed care population (3 MCOs). CHIP only rate: 17.1 per 1,000 beneficiary months.

KS:          Rate includes managed care population (3 MCOs).

KY:          Rate includes managed care population (5 MCOs), representing 95 percent of the population. Rate excludes FFS population, representing 5 percent of the population. Rate was validated by certified HEDIS auditors.

LA:          Rate includes FFS and managed care populations (5 MCOs). Rate was calculated using HEDIS-certified code and the state conducted an internal validation of the data.

ME:         Rate includes FFS population.

MD:        Rate includes managed care population (8 MCOs), representing 95 percent of the population. Rate excludes FFS population, representing 5 percent of the population. Rate was audited by certified HEDIS auditors.

MA:        Rate includes PCCM and managed care populations (5 MCOs), representing 74 percent of the population. Rate excludes FFS population, representing 26 percent of the Medicaid population and 18 percent of the CHIP population, but the majority of these children would not have been measure-eligible, including children who have other primary insurance, children with limited Medicaid benefits, children in premium assistance programs, new enrollees who have not yet enrolled in an MCO, and children in state custody.

MI:          Rate includes managed care population (11 MCOs), representing 80 percent of the population. Rate excludes FFS population, representing 20 percent of the population. MCO rates were validated by the state's EQRO.

MN:        Rate includes FFS and managed care populations (8 MCOs). Rate includes paid claims only. Rate was audited by a certified HEDIS auditor.

MS:         Rate includes managed care population (2 MCOs).

MO:        Rate includes managed care population (3 MCOs), representing 92 percent of the Medicaid population and 58 percent of the CHIP population. Rate excludes FFS population, representing 8 percent of the Medicaid population and 42 percent of the CHIP population. MCO rates were audited by a HEDIS certified vendor.

MT:         Rate includes FFS population.

NE:          Rate includes FFS and managed care populations (3 MCOs).

NV:         Medicaid rate includes managed care population (3 MCOs). Rate excludes FFS population. CHIP rate includes managed care population (3 MCOs). Rate excludes FFS population. CHIP only rate: 25.1 per 1,000 beneficiary months.

NH:         Rate includes managed care population (2 MCOs), representing 88 percent of the population. Rate excludes FFS population, representing 12 percent of the population. MCO rates were audited by certified HEDIS auditors.

NJ:          Rate includes managed care population (5 MCOs), representing 93 percent of the population. Rate excludes FFS population, representing 7 percent of the population.

NM:        Rate includes managed care population (4 MCOs). MCO rates were audited by certified HEDIS auditors.

NY:          Rate includes managed care population (19 MCOs), representing more than 90 percent of the population. Rate excludes FFS population, representing less than 10 percent of the population. State conducted an internal validation of the data.

NC:         Medicaid rate includes FFS and PCCM populations. Rate was validated by an NCQA-certified vendor.  CHIP rate includes FFS and PCCM populations ages 6 to 18. Rate was validated by an NCQA-certified vendor. CHIP only rate: 25.4 per 1,000 beneficiary months.

OH:         Rate includes managed care population (5 MCOs), representing 93 percent of the population. Rate excludes FFS population, representing 7 percent of the population.

OK:         Rate includes FFS and PCCM populations. Rate excludes enrollees in home- and community-based services waivers.

OR:         Rate includes managed care population (16 CCOs), representing 88 percent of the population. Rate excludes FFS population, representing 12 percent of the population.

PA:          Rate includes managed care population (19 MCOs). Data were submitted by MCOs and compiled by the state's EQRO.

RI:           Rate includes managed care population (2 MCOs), representing 85 percent of the population. Rate excludes FFS population, representing 15 percent of the population.

SC:          Rate includes managed care population (5 MCOs).

TN:          Medicaid rate includes managed care population (4 MCOs). Rate was validated by the state's EQRO. CHIP rate includes the CHIP Health Plan Administrators and Medical Benefits Managers population. Rate was validated by the state's EQRO. CHIP only rate: 25.5 per 1,000 beneficiary months

TX:          Medicaid rate includes FFS and managed care populations (34 MCOs). Rate was validated by the state's EQRO. CHIP rate includes managed care population (17 MCOs). Rate was validated by the state's EQRO. CHIP only rate: 23.9 per 1,000 beneficiary months.

UT:          Medicaid rate includes managed care population (3 MCOs), representing 35 percent of the population. Rate excludes FFS population and enrollees in one MCO, representing 65 percent of the population. MCO rates were audited by certified HEDIS auditors. CHIP rate includes managed care population (1 MCO), representing 44 percent of the population. Rate excludes enrollees in one MCO, representing 56 percent of the population. MCO rate was audited by certified HEDIS auditors. CHIP only rate: 13.1 per 1,000 beneficiary months.

VT:          Rate includes statewide 1115 waiver population enrolled in a public non-risk prepaid inpatient health plan population, representing the total Medicaid population. Rate was validated by the state's EQRO.

WA:        Rate includes managed care population (5 MCOs), representing 97 percent of the population. Rate excludes FFS and PCCM populations, representing 3 percent of the population. Rate also excludes managed care populations who met the continuous eligibility requirement for Medicaid or CHIP but who were not enrolled in a single plan during the continuous enrollment period. Rate was audited by the state's EQRO.

WV:        Medicaid rate includes FFS and managed care populations (4 MCOs). Rate includes paid claims only. CHIP rate includes FFS population. CHIP only rate: 35.7 per 1,000 beneficiary months.

WY:        Medicaid rate includes FFS population. CHIP rate includes managed care population (1 MCO). CHIP only rate: 26.6 per 1,000 beneficiary months.