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LETTER |
At the time of the study, Henrie M. Treadwell was with the W. K. Kellogg Foundation, Battle Creek, Mich. Marguerite J. Ro is with the School of Dental and Oral Surgery Division of Community Health, Columbia University, New York, NY. Carolina Casares is with the National Center for Primary Care, Morehouse School of Medicine, Atlanta, Ga.
Correspondence: Requests for reprints should be sent to Henrie M. Treadwell, PhD, National Center for Primary Care, Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA 30010 (e-mail: htreadwell{at}msm.edu).
We applaud Schanzer and Morgan’s study examining emergency department (ED) use. However, we disagree with the characterization of underprivileged men as "abusers" of the ED and the interpretation that these men are "overusing" the ED. The use of the term "abusers" is particularly unwarranted as it further negatively stereotypes underserved men whose burden is unduly heavy as a result of being poor, being under- or unemployed, and, often, coming from communities lacking resources. The terms "in excess" and "overuse" suggest an assumption that all men, regardless of insurance coverage, income, or race/ethnicity, are equally able to access primary and preventive care—a notion that was firmly negated in the recent Institute of Medicine report Unequal Treatment.1
Emergency departments are a vital component of the health care safety net, particularly for the uninsured, those with low incomes, and people of color.2 There is no question that a portion of ED visits could be handled in lower-cost primary care settings.3 However, few studies have gone beyond examining ED use and sociodemographic factors to ask why certain populations are choosing the ED as their primary source for nonurgent care. Previous studies have shown that major reasons that patients seek care in the ED include not being able to secure care at an alternative location in a timely fashion and other nonfinancial barriers.4,5 And for those who suffer from mental illness and substance abuse issues, the ED is the first stop for their continuum of care.
To understand the implications of ED use as related to insurance coverage and income requires a closer examination of service fees, payment rates, and safety-net funding. While patients with private insurance are likely to have their ED care covered by insurance, it has been common practice for hospitals to charge the highest prices to uninsured patients, who are often the least able to pay.6 Commercial health insurers and government plans negotiate discounted rates for their customers. Disproportionate share–hospital funds and indigent-care funds are available to offset some of the cost of caring for uninsured and publicly insured patients; however, better accountability of these funds is needed to ensure that these funds benefit the health of the poor.7 There may be abuse involved somewhere, but it is hard to see how it is the poor who are the abusers in a payment system that is unfettered and uncontrolled.
Ultimately, equal access to care and appropriate use of services at all levels are desirable goals. This is why we must make the health and health care issues of poor men and men of color visible.
References
1. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003. Also available at: http://www.nap.edu/catalog/10260.html. Accessed March 20, 2004.
2. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary. Adv Data Vital Health Stat. June 4, 2003;335.
3. Davis K. The costs and consequences of being uninsured. Med Care Res Rev.2003;60(suppl June):89S–99S.
4. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. Ambulatory visits to hospital emergency departments: patterns and reasons for use. JAMA.1996;276:460–465.[Abstract]
5. Walls CA, Rhodes KV, Kennedy JJ. The emergency department as usual source of Medicare care: estimates from the 1998 National Health Interview Survey. Acad Emerg Med.2002;9:1140–1145.[ISI][Medline]
6. Perez-Pena R. Hospitals agree to lower fees for uninsured. New York Times:B1. February 3, 2004.
7. Weissman JS. Uncompensated hospital care: will it be there if we need it? JAMA.1996;276:823–828.[Abstract]
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