The Follow-Up on Follow-Ups Looks Bleak
The Follow-Up on Follow-Ups Looks Bleak
Abstract & Commentary
By Theodore Chan, MD, FACEP Dr. Chan is Professor of Clinical Medicine, Medical Director, Department of Emergency Medicine, University of California San Diego Medical Center, San Diego Dr. Chan reports no financial relationships with companies having ties to this field of study.
Source: Asplin BR, et al. Insurance status and access to urgent ambulatory care follow-up appointments. JAMA 2005; 294:1248-1254.
Timely follow-up care is necessary to prevent adverse outcomes in patients who are discharged from the emergency department (ED). In particular, it may be unsafe to discharge a patient with a potentially serious health problem if timely and appropriate follow-up care cannot be ensured following the visit to the ED.
In this multiregional study, investigators studied the effect of insurance status on availability and access to follow-up appointments for simulated ED patients. Research assistants posed as patients discharged from the ED with one of three clinical syndromes requiring urgent follow-up: pneumonia, asymptomatic accelerated hypertension, and possible ectopic pregnancy. Using the telephone, they contacted nearly 500 local referral clinics for EDs in nine different cities (Phoenix, Los Angeles, Denver, Jacksonville, Atlanta, Chicago, Minneapolis/St. Paul, New York, and Dallas/Ft. Worth) attempting to obtain a follow-up appointment within seven days of the reported ED visit. These fake patients offered the following insurance coverage information to clinic staff: private insurance; Medicaid; uninsured but willing to pay up to $20 cash and negotiate a payment plan at the visit; or uninsured but willing to pay the full cash price of the visit.
The investigators found that nearly all clinics performed a financial coverage screening on callers (98%), whereas only 28% attempted to determine the severity of the caller’s condition. Callers with private insurance were more likely than Medicaid callers (63.6% vs 34.2%, respectively) and more likely than uninsured patients willing to pay $20 initially (65.3% vs 25.1%, respectively) to obtain a timely follow-up appointment. Interestingly, there were no differences in follow-up appointment rates between private insurance callers and uninsured callers willing to pay the full amount of the clinic visit (66.3% vs 62.8%). The investigators found no difference based upon the clinical vignette used and only slight differences based upon whether the clinic was a safety net or non-safety net. There was geographic variation based on region studied, most notably in access availability for Medicaid patients, which ranged from as low as 8.3% to as high as 64.5% of callers being offered prompt follow-up appointments. Based upon their study, the authors concluded that reported insurance status is associated with access to timely follow-up for patients discharged from the ED with serious conditions.
Commentary
The growing trend toward outpatient management for many serious conditions seen and treated in the ED requires that patients have timely access to appropriate follow-up care. This fascinating study quite clearly demonstrates what many of us already suspected or witnessed – that insurance status markedly affects the availability of prompt follow-up care for patients. Both uninsured and Medicaid patients were much less likely to be offered prompt appointments than patients with private insurance. Similarly, the marked variability and range of follow-up rates by different regions for Medicaid patients likely are related to the variability in state-determined reimbursement rates for this program. What is even more notable, however, is the fact that nearly 40% of private insurance patients and those offering to pay cash were unable to obtain timely follow-up appointments as new patients. This finding raises real questions regarding the capacity of clinics—and even safety net providers—to provide care, not only for the uninsured and underinsured, but for all patients who need care. While this study focuses on new patients seeking follow-up care after ED discharge, prior studies have demonstrated that having a usual source of care does not guarantee timely access to care.1 Ultimately, many EDs have resorted to having patients return for follow-up care—a practice that ensures patients some access to follow-up, but ultimately adds to the growing problem of ED crowding.
Reference
1. Sarver JH, et al. Usual source of care and nonurgent emergency department use. Acad Emerg Med 2002; 9:916.
Timely follow-up care is necessary to prevent adverse outcomes in patients who are discharged from the emergency department (ED). In particular, it may be unsafe to discharge a patient with a potentially serious health problem if timely and appropriate follow-up care cannot be ensured following the visit to the ED.Subscribe Now for Access
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