Cash benefits help cut emergency department utilization

For hospitals and health systems looking to reduce costly emergency department overutilization, the key could be as simple as cash benefits, according to new JAMA data.

The report, published by researchers from Mass General Brigham and Harvard Medical School, showed that offering up to $400 cash benefits for low-income patients significantly reduced ED utilization and improved access to specialty care.

These findings come as health policy researchers look into social determinants of health (SDOH) interventions that can improve patient access to care, patient outcomes and overall hospital margins and operations. This particular study focused on income, a key SDOH that affects patient access to care and healthcare affordability.

"Poverty is associated with greater barriers to health care and worse health outcomes," the researchers wrote in the study's introduction. "Much of this relationship could be the result of confounding factors and reverse causality rather than income itself. Therefore, whether income support can independently improve health remains an open question in the U.S."

The JAMA report chips away at that question, showing that cash benefits can at least support more judicious healthcare access and utilization.

The study, which included 2,880 adults living in a low-income community outside Boston, divided participants into a control and intervention group using a randomized lottery system. Intervention group participants received a debit card containing up to $400 each month for a total of nine months.

Those cash benefits had a marked effect, the researchers said, at least in terms of healthcare utilization. During the study period, individuals receiving the benefits had around 100 fewer ED visits per 1,000 people than those receiving usual care (217.1 versus 317.5 visits, respectively).

That shook out to reductions in ED visits related to behavioral health (21 fewer visits) and substance use (around 13 fewer visits) among the cash benefits group. The cash benefits group also saw 27 fewer ED visits that resulted in hospitalization.

Such results are all beneficial for a hospital or health system trying to manage its ED utilization rates.

The ED is a notoriously expensive place to receive care, and most hospitals and health systems are staring down ED overcrowding problems. Keeping patients out of the ED, either because they have the means to practice better chronic disease management or the ability to appropriately access care in low-acuity settings, is a key financial goal for many hospitals.

Still, the data did not show a significant increase in outpatient care access for individuals receiving the $400 benefits. This includes limited change in patient access to outpatient primary care or outpatient behavioral health.

These findings indicate that reductions in ED utilization were mostly due to overall better health, not more accessible pathways to low-acuity care settings.

"Financial strain is associated with reduced cognitive bandwidth, more mental illness and greater use of alcohol and other substances," the researchers said. "The cash benefit, by reducing financial strain and improving economic resilience, may have had direct positive effects on the mental health of lower-income individuals."

Patient access to other subspecialties increased, especially among individuals without a car, the researchers said. Increased access to subspecialty care rather than primary care could indicate differences in care access barriers.

Primary care access is generally readily available in the study site, but subspecialty care access usually requires travel into downtown Boston, which can be both costly and burdensome, the researchers said. The cash benefit had the combined effect of helping patients afford medical bills for subspecialty care as well as the transportation they'd need to take to access it, the researchers posited.

As noted above, reducing ED utilization in exchange for better access to outpatient care benefits health system finances. Although the study did not have access to cost or billing data for individuals enrolled in the cash benefit program, the researchers did estimate a rough $450 savings per person over nine months.

Those savings would cover between one-sixth and one-seventh of the cost of paying out the cash incentives in the first place, the study authors estimated.

"Policies that alleviate poverty by providing income support in the form of cash benefits may produce important benefits for health and access to health care," the researchers concluded.

Sara Heath has covered news related to patient engagement and health equity since 2015.