JACR: Uninsured may be unscanned in the ED

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Emergency Room, ER, hospital - 19.26 Kb

Insurance status can influence the level of imaging services patients receive in the emergency department (ED), with uninsured patients and those on Medicaid receiving fewer imaging services than those with private insurance, according to a study in the January issue of the Journal of the American College of Radiology.

Study authors Kimberly E. Applegate, MD, MS, of Emory University School of Medicine in Atlanta, and James W. Moser, PhD, of Econometrica, a private research and management consulting firm in Bethesda, Md., noted in the study background information that previous studies found that ED visits are more likely for the uninsured, people below the poverty line and those in poor health, but for the current study they were concerned with the type of services those patients received when they get to the ED.

“On average, Americans without health insurance receive fewer healthcare services than those with insurance,” said Applegate. “However, the specific types of services for which the uninsured face access and utilization deficits are not well understood.”

The authors’ main source of data was the 2004 National Hospital Ambulatory Medical Care Survey, which included information on the source of payment and the imaging services rendered during ED visits. Patients were divided into three categories–uninsured, Medicaid and non-Medicaid insured–and relative value units (RVUs) were assigned to imaging procedures.

Results showed that, compared with insured persons, non-elderly uninsured and Medicaid patients received 8 percent and 10 percent fewer ED imaging services, respectively. Uninsured patients received services with 13 percent fewer RVUs than insured patients; services for Medicaid patients had 19 percent fewer RVUs.

“These differences amplify the potentially serious health implications for persons lacking conventional health insurance,” wrote the authors. “As the number of uninsured Americans continues to rise, the use of ED services will also rise.”

The authors provided a number of possible explanations for the disparity in ED imaging services administered. Insured patients have more access to imaging services at physicians’ offices that are not mandated to provide care to uninsured or Medicaid patients, as general hospital ED departments must do, which could skew the numbers. Applegate and Moser also cited malpractice concerns as a potential motivator. Physicians may believe they are less likely to be sued by uninsured patients and are thus less likely to practice defensive medicine.

The researchers also said that rather than uninsured and Medicaid patients receiving too few services, the disparity may actually be caused more by insured patients receiving too many services.

“This is a possibility, given that insured persons typically pay only a fraction of the bill and are therefore likely to overutilize healthcare to the point at which social cost exceeds benefit,” wrote the authors. “There are many incentives for ED providers to order tests and imaging—respond to patient demand, minimize the time patients spend in the ED, decrease malpractice risk—and virtually none not to order them.”

Future research should focus on determining whether uninsured patients receive too little imaging or whether insured patients receive unnecessary imaging, according to the authors.