Are emergency departments really a “safety net” for the medically indigent?

Abstract

This study was designed to quantify the willingness of emergency departments (EDs) and private care practitioners to see medically indigent patients. Three case scenarios were developed to represent severe, moderate, and mild problems that typically confront ED physicians. A female investigator made telephone calls using these scenarios, each time declaring herself to be medically indigent. All EDs received calls about all three scenarios, but only the least severe scenario was used for private practitioners. The timing and order of all calls were randomized. A control survey of the same population was subsequently performed in which the caller related that she had third-party insurance and had the minimal (rash) problem. The participants were all 54 nonmilitary EDs in Arizona and 69 randomly chosen private primary care practitioners in the same locales as the EDs. Calls to EDs were made during all time periods and days of the week; private practitioners were called only during their weekday office hours. The majority of all EDs were willing to see medically indigent patients, recommending that the caller come to the ED immediately 76% of the time. This response did not vary by geography or the facility's size, although ED personnel suggested initial home treatment more commonly at smaller hospitals ( P = .02), and suggested coming to the ED more often on weekends ( P < .02). Some EDs, however, clearly did not comply with their own telephone advice policies, and some ED personnel failed to give medically appropriate advice. In contrast to the EDs ( P < .001), 62% of private practitioners' staffs stated they were not taking new patients or required at least $30 in advance. Private practitioners in the largest communities were significantly more reluctant to see the medically indigent than their peers in smaller communities ( P < .05). For an insured caller, 55% of private practitioners would see the caller for <$30 and only 35% were not taking new patients or provided referral. In contrast to most private primary care practitioners, EDs are at least willing to serve as a triage point for the medically indigent and are often the primary-care “safety net” for the medically indigent.