Correspondence
Access of Medicaid Recipients to Outpatient Care
N Engl J Med 1994; 331:877-878September 29, 1994
- Article
To the Editor:
The Medicaid Access Study Group's telephone survey of 953 ambulatory care sites in 10 cities, including Sacramento (May 19 issue), found that Medicaid recipients in urban areas have limited access to outpatient care apart from that offered by hospital emergency departments1. The article mentions the practice at the University of California, Davis, of sending patients with nonemergency problems to other ambulatory care sites. The survey found that only 22 percent of the 120 ambulatory care sites studied in Sacramento were willing or able to treat a Medicaid recipient within two days after the call. We disagree with the conclusion that there should be a moratorium on the practice of sending Medicaid recipients out of the emergency department.
Although a minority of the Sacramento ambulatory care sites were willing or able to see patients within two days, the study did not demonstrate that care was unavailable, only that it was difficult to arrange without guidance. Since July 1988, our emergency department has been sending elsewhere all patients, regardless of the payer category (private insurance, county coverage, Medicaid, or self-paying), who are identified as having nonemergency problems. We provide each of these patients with a list of referrals that are appropriate for the specific payer category. The patients should have reasonable access to care because the lists of clinics are updated frequently. Our outcome data have been published2-4. We believe this is a system that works to the benefit of society by reserving emergency resources for patients most likely to have urgent problems.
Over the past six years, we have found that at any given time only 15 to 20 percent of clinics in Sacramento accept Medicaid recipients as patients. This practice has compounded the problem of overcrowding in emergency departments. Future efforts should be directed toward increasing the availability of ambulatory care for nonurgent problems rather than perpetuating the costly and often suboptimal alternative of emergency department care.
The Medicaid Access Study Group has shown that the telephone book is a poor source of health care referrals for Medicaid recipients. This problem can be circumvented by identifying, in advance, health care facilities that are willing to take Medicaid recipients, as long as a sufficient number of such facilities are available.
4 ReferencesRobert W. Derlet, M.D.
Donna Kinser, M.D.
University of California, Davis, Sacramento, CA 958171
The Medicaid Access Study Group
Full Text | Web of Science | Medline2
Derlet RW ,Nishio DA . Refusing care to patients who present to an emergency department. Ann Emerg Med 1990;19:262-267
CrossRef | Web of Science | Medline3
Derlet RW ,Nishio D ,Cole LM ,Silva J Jr . Triage of patients out of the emergency department: three-year experience. Am J Emerg Med 1992;10:195-199
CrossRef | Web of Science | Medline4
Derlet RW ,Kinser D . The emergency department and triage of nonurgent patients. Ann Emerg Med 1994;23:377-379
CrossRef | Web of Science | Medline
To the Editor:
The editors are to be commended for “Setting the Record Straight in the Breast-Cancer Trials” (May 19 issue) and, in so doing, making a strong statement against fraud in medical research1. Yet in the same issue the Medicaid Access Study Group describes a survey in which a form of fraud was used as a research method. Trained research assistants misrepresented themselves as Medicaid recipients and as patients with private insurance and falsely reported various symptoms in order to obtain data about access to medical care.
Perhaps the authors believe, as did Dr. Poisson,2 that good ends justify such means. However, fraud is fraud, and data obtained through fraud do not yield scientific knowledge. The medical encounter must be built on mutual trust. Such research adds to the many factors now tending to make it an adversarial relationship. Furthermore, various signals, unconscious (tone of voice, for example) and conscious (such as inconsistent symptoms), may skew the responses and call the results of such studies into question.
The use of stings by faux patients to obtain data about medical practice or access to it should be condemned. Since access to medical care is such an important concern, why not study it honestly? Just ask.
2 ReferencesC.D. Bessinger, Jr., M.D.
10 Enterprise Blvd., Greenville, SC 296151
Angell M ,Kassirer JP . Setting the record straight in the breast-cancer trials. N Engl J Med 1994;330:1448-1450
Full Text | Web of Science | Medline2
Poisson R . Fraud in breast-cancer trials. N Engl J Med 1994;330:1460-1460
Web of Science | Medline
To the Editor:
The dishonesty of the researchers falsely representing themselves as Medicaid recipients warrants review. The fact that they misrepresented themselves to businesses rather than to individual people does not obviate the need for truthfulness. Honesty is always a good policy and should be the only policy for health care providers.
Stewart G. Pollock, M.D.
1871 Evelyn Byrd Ave., Harrisonburg, VA 22801-7500To the Editor:
The Medicaid reimbursement in my area is $7.50 per office visit. My office overhead is roughly the same as that of most primary care physicians, ranging between 45 and 55 percent of the normal fee of $45 for an office visit, which the Medicaid reimbursement does not come close to covering. A primary care physician cannot take on patients with this level of reimbursement and stay in practice for any length of time. When I first went into practice, in 1970, the Medicaid reimbursement for an office visit was $7.20. Reimbursement has thus increased by 30 cents in the past 24 years. Until Medicaid programs keep up with costs, particularly in private physicians' offices, a large group of people will not have an appropriate source of outpatient medical care.
J.E. Pipas, M.D.
2514 E. Genesee St., Syracuse, NY 13224Author/Editor Response
The authors reply:
To the Editor: Our study was conducted to determine whether Medicaid recipients can readily gain access to outpatient care. The majority of the primary care providers we contacted could not or would not accommodate a Medicaid recipient's request to be seen. It was particularly difficult for our callers to get an appointment within two days or after 5 p.m. These observations suggest that efforts to reduce Medicaid costs by restricting access to emergency department care may jeopardize the health of this vulnerable group of people.
We agree with Dr. Pipas that inadequate reimbursement for primary care is the principal cause of this problem. However, noneconomic factors also limit access to primary care1. Few Medicaid recipients choose the emergency department for convenience. Most choose it because it is the best of a poor set of options2.
Drs. Derlet and Kinser suggest that some patients can safely be refused care in the emergency department. However, others have found that the triage criteria used at their hospital can misclassify patients with serious conditions3,4. The observation that outpatient care in Sacramento is “difficult to arrange without guidance” is hardly reassuring. Many patients who are turned away from their emergency department are lost to follow-up5.
Direct observation generally yields more accurate information than reports by patients or physicians. We did not inform the clinic employees of the nature of our study because we were concerned that this might alter their usual response to a Medicaid recipient's request to be seen. We did not request or record the name of any clinic employee contacted during the study. All interviews were conducted over the telephone; no face-to-face encounters took place. We did not ask intrusive or personal questions, and every appointment was canceled shortly after it had been made. Elaborate precautions were taken to protect the confidentiality of individual physicians and primary care practices. For these reasons, 10 institutional review boards approved our study methods or found the study to be exempt from their review.
Despite these assurances, Drs. Bessinger and Pollock question the ethics of this kind of research. We do not believe that the sensibilities of medical colleagues are more important than the welfare of patients. Our findings confirm that many of the nation's urban poor do not have ready access to outpatient care. Until they do, they should not be denied treatment in hospital emergency departments.
5 ReferencesArthur L. Kellermann, M.D., M.P.H.
Emory University School of Public Health, Atlanta, GA 30322Garen Wintemute, M.D., M.P.H.
University of California, Davis, Sacramento, CA 95817Louis Binder, M.D.
Texas Tech University, El Paso, TX 799051
Rask KJ ,Williams MV ,Parker RM ,McNagny SE . Obstacles predicting lack of a regular provider and delays in seeking care for patients at an urban public hospital. JAMA 1994;271:1931-1933
CrossRef | Web of Science | Medline2
Kellermann AL . Nonurgent emergency department visits: meeting an unmet need. JAMA 1994;271:1953-1954
CrossRef | Web of Science | Medline3
Lowe RA ,Bindman AB ,Ulrich SK , et al. Refusing care to emergency department patients: evaluation of published triage guidelines. Ann Emerg Med 1994;23:286-293
CrossRef | Web of Science | Medline4
Birnbaum A ,Gallagher EJ ,Utkewicz M ,Gennis P ,Carter W . Failure to validate a predictive model for refusal of care to emergency department patients. Acad Emerg Med 1994;1:213-217
CrossRef | Medline5
Derlet RW ,Nishio DA . Refusing care to patients who present to an emergency department. Ann Emerg Med 1990;19:262-267
CrossRef | Web of Science | Medline
