Costly care: Increased ambulatory care sensitive expenditures due to unmet healthcare need among children in the US

We sought to determine if unmet healthcare need was associated with ambulatory care sensitive (ACS) emergency room and inpatient expenditures among children in the US, using a nationally representative, population-based sample. We examined data on 22,581 children from the 2002-2007 Medical Expenditure Panel Survey. Unmet need was defined as delayed or forgone healthcare during the first survey year. Charges, expenditures and out-of-pocket (OOP) costs associated with ACS utilization were evaluated during the second survey year. Expenditures for non-ACS utilization during the second survey year were also evaluated as a point of comparison. Multivariable two-part models were used to determine if children who experienced past year unmet healthcare need had higher ACS expenditures in the following year, adjusting for predisposing, enabling and need factors. 4.77% of children with unmet need experienced any expenditures associated with ACS visits, compared to 3.02% for those without unmet need (p<0.01); while 11.57% of children with unmet need experienced any expenditures associated with non-ACS visits, compared to 12.23% for those without unmet need (p=0.03). Multivariable analyses revealed that children with unmet need had 69% higher odds of any ACS charges compared to children without unmet need (95% CI: 1.15-2.49), but there were no significant difference in the odds of experiencing any non-ACS charges for children with and without unmet need (OR 1.19, 95% CI: 0.97-1.45). Non-ACS expenditures and OOP costs were not significantly different for those children with and without unmet need. Children with unmet need were more likely to have any ACS expenditures than children without unmet need; while among those with any ACS expenditures, children with unmet need had significantly lower charges and expenditures but significantly higher OOP costs. As unmet need was associated with increased ACS utilization but not non-ACS utilization, it is less likely that the difference in ACS utilization was driven by a general preference to receive care in a hospital. Instead, families may be substituting prior delayed or forgone ambulatory care with emergency room and inpatient care. Although families may be seeking care in the ER instead of a clinic because of less generous insurance coverage, they appear to incur higher OOP costs as a result. Regardless of the mechanism, children with unmet need and high ACS utilization reflect families with clear barriers to accessing appropriate preventive care. Ensuring that families understand their insurance benefits may help to ensure appropriate utilization while simultaneous decreasing their OOP costs.