Disparities in treatment of children in the emergency department based on their insurance status
In 2009, children with public insurance were three times more likely and children with no insurance were eleven time more likely not to have a primary care physician, compared with children with private insurance. Without a primary care physician, the Emergency Department (ED) often becomes the primary point of contact for treatments and diagnoses. A new study scheduled for publication in The Journal of Pediatrics reports that children with private, public, and no insurance may receive differing levels of treatment in EDs.
Rebekah Mannix, MD, MPH, and colleagues from Children's Hospital Boston, retrospectively assessed 84,536 ED visits of children ≤18 years of age in 1999-2008, using the National Hospital Ambulatory Medical Care Survey, which is an annual survey of ~480 hospital EDs. Over the 10-year period, researchers found that 45% of children in the ED had private insurance, 43% had public insurance (Medicaid or State Children's Health Insurance Program), and 12% had no insurance. Compared with children with private insurance, those with public or no insurance were almost 25% less likely than those with private insurance to undergo testing, receive a medication, or undergo any procedure when seeking care in the ED. Although children with public insurance were 20% more likely to be diagnosed with a significant illness compared with children with private insurance, there was no difference in the level of treatment based on insurance status among children with significant illnesses.
It is unclear whether these insurance-based differences represent under treatment in children without private insurance, over treatment in children with private insurance, or appropriate care for all. Dr. Mannix reminds us that "because ED physicians are salaried or paid by the hour, it is uncertain how or why a child's insurance status could be associated with care decisions in the ED." Although the authors speculate that the disparities could be due to a variety of reasons, they note that further studies are needed to assess insurance-associated outcomes.