ED Equality

FigureFigurePerhaps no patient in America so visibly illustrates the plight of uninsured patients who receive emergency care as the Utah woman who lived with half a skull for four months. After her car crashed amid ice and snow on a road near Salt Lake City, sending her plunging through the windshield, the only apparent way to staunch the bleeding in her brain was to take out some of her cranial bone. This emergency treatment after the crash was widely credited in news accounts — and by her — as life-saving. But after that first critical period of intense medical intervention, the young woman's care took an interesting twist: She was sent home from the hospital to await surgery rather than receiving a more timely operation to reimplant her removed bone. Meanwhile, her missing skeletal component was put in a freezer as Medicaid and the hospital bickered over who would pick up the next surgical tab, according to a story by the Associated Press. In the intervening weeks, she wore a sports helmet nearly constantly to protect her brain and suffered pain throughout the ordeal. While a dramatic example by anyone's reckoning, the incident actually comes as no surprise to emergency physicians in Rochester, NY, who spent months investigating their own emergency department to determine whether disparities of care in the uninsured can be documented. Their findings don't dispute that they do occur, but typically such disparities apparently happen only after the emergency department visit, not during it. That seems to be what took place after the head-shattering incident on a canyon road in Utah. But is that the usual chain of events for an uninsured patient? Data from the Rochester team suggest it might be, though the researchers there only took the analysis as far as the ED. “We wanted to find out if we [in the ED] treat everybody the same,” said Frank Zwemer, MD, the vice chairman of emergency medicine at the university and the clinical director of emergency department at Strong Memorial Hospital. “And, as it turns out, it seems like we do.” By evaluating the records of 80,000 patient care encounters in an academic tertiary care center, researchers at the University of Rochester reached the conclusion that there were no differences in ED care related to insurance status, except that fewer radiographic studies were ordered for uninsured patients. The team looked at traumatic injuries and at cardiovascular disease, and found no evidence of discrimination in care, though such a discrepancy has been suggested in much of the medical literature, perhaps most strongly by a report from the Institute of Medicine (IOM), “Care Without Coverage.” The IOM report, which compared the same kinds of patients as did Dr. Zwemer and colleagues, evaluated hospital services. Uninsured patients did receive fewer services, according to that report. “What we tried to do is a very specific thing,” which was to determine whether this actually occurred in the ED, he said. “We found there was no tremendous bias.” The results may sound like pure logic. After all, emergency physicians are trained to take care of patients on the spot, and if they are doing their job, they make no decisions based on factors other than medical necessity. Still, there is such a disproportionately high number of uninsured patients in this setting that there was some finger-pointing going on, as study after study documented disparity in care.Figure“We wanted to find out if [the ED treats] everybody the same, and, as it turns out, it seems like we do.” Dr. Frank Zwemer Unfortunately, noted Faber White, MD, a co-investigator with Dr. Zwemer, the results they obtained haven't aroused much interest in making distinctions between emergency care and in-hospital patient stays. “This hasn't gotten much attention outside the medical community,” he noted. Although the data received a positive response when it was presented at a national meeting, Dr. Zwemer said he has been unable to find a journal willing to publish the paper he and his co-authors wrote about the findings. Payment for Care Lack of attention wasn't a problem for a group at Case Western. In a study similar in intent to Dr. Zwemer's except it aimed to identify characteristics of the uninsured rather than their care, Rita Cydulka, MD, and several of her colleagues in Cleveland found that income failed to predict who is likely to pay for their care. They were stunned — and so were those who heard about the results of the study. “We got calls from a number of news agencies,” said Dr. Cydulka, an associate professor and the vice chairwoman of emergency medicine at MetroHealth Medical Center/Case Western Reserve Medical School. In fact, when the findings were presented at the Society for Academic Emergency Medicine, “people said they just didn't believe it.” Using data drawn from the 1999 Medical Expenditure Panel Survey, Dr. Cydulka and colleagues were able to evaluate the distribution of out-of-pocket and third-party payments received for emergency department visits, and they were able to determine the extent to which the uninsured pay their ED charges. The analysis was limited to those either completely uninsured or those with insurance coverage. As a result, they were able to answer this question: Do the uninsured pay their way? They found that differences between those who did and did not try to pay their ED charges were not related to age, race, gender, education, income, or employment. In fact, for 12 percent of emergency department visits by the uninsured, the full charge was paid exclusively out of pocket. For those uninsured patients with incomes below poverty level, a single out-of-pocket payment sometimes exceeded five percent of their annual family income, she noted. However, about half of the uninsured patients made no such payments. Third-party payments accounted for a “surprising proportion of payments” for those who identified themselves as “uninsured,” which suggests this is a group that needs to be characterized more fully, she stressed. Preference for the ED Emergency physicians at several academic centers have sought to pin down profiles of the uninsured to better understand and characterize this patient population. A group at Montreal Hospital in Quebec, seeking to determine why these patients are not receiving care from a primary care provider before presenting to the ED, undertook a cross-sectional study at five tertiary care hospitals in 2000. They found that patients had different reasons for visiting their local ED instead of their primary care provider, ranging from the perception of easier access at an emergency department to having substantial trust in the care they would receive there. In fact, patients with non-urgent conditions reported not visiting their primary care provider due to the following considerations: issues of accessibility (34%); a need for follow-up at the ED (19%); their familiarity with the ED (19%); the perception of need for care at the ED (16%); and their feeling of trust toward the ED (10%). The findings were presented at last year's annual meeting for Society for Academic Emergency Medicine. At the same meeting, the late Peter Lane, MD, and a group of emergency physicians from Philadelphia presented an analysis of the demographic and socioeconomic characteristics of both the insured and the uninsured. Using data from the Medical Expenditure Panel Survey from 1996 to 1998, they found no statistical differences between the groups in terms of the frequency of ED visits. They did find, however, intriguing aspects of the patient groups, such as the majority of uninsured patients were employed — and to an even greater degree than were the insured patients. In fact, though the uninsured had less education than their insured counterparts, they were more likely to be working. The most frequent conditions in both groups were accidental injuries and poisonings and respiratory and gastrointestinal diseases. Of the 47,208 people surveyed, the mean age for the uninsured was about 29 years, and more than half were women. Five years ago, the U.S. Census Bureau estimated that more than 43 million Americans were uninsured, and those figures are believed to have grown substantially. To help those in public office and in government assess and evaluate proposals and create policies for meeting the needs of the nation's uninsured, the IOM stepped in with an examination of the issue. In fact, the IOM published several reports, and in its most recent, “Insuring America's Health: Principles and Recommendations” published only this year, the institute found that lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States.Figure“People said they just didn't believe it.” Dr. Rita Cydulka This latest report culminates a research series that is believed to offer the most comprehensive assessment of the consequences of no health insurance on individuals, their families, communities, and the whole society. It points out that although America leads the world in health care spending, it is the only wealthy, industrialized nation that does not have a program giving all citizens the necessary insurance coverage to ensure access to care. The IOM report does not recommend a specific coverage strategy for these people. Rather, the committee that formulated it shows how various approaches could extend coverage and achieve certain of the committee's principles. The committee offers a set of guiding principles based on the evidence reviewed in five previous reports and on new analyses of past and present federal, state, and local efforts to reduce the number of uninsured. The institute said health care coverage should be universal, continuous, offered in a way that is “affordable and sustainable” for society at large, and “enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.”Figure“This hasn't gotten much attention outside the medical community.” Dr. Faber White Although the IOM states that all of these guiding principles are necessary, the institute emphasizes the most basic and important part of the proposal is universal coverage. The IOM has issued a call for universal health insurance, and is urging President Bush and Congress to “act immediately by establishing a firm and explicit plan to reach this goal.”

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