- Email: [email protected]
Emergency Departments and Uninsured Children: An Enrollment Opportunity
Editorials
Dueling Meta-Analyses
Address for reprints: Robert M. Williams MD, DrPH, School of Public Health, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029;
Robert L. Wears, MD, MS
231-938-2494, fax 231-938-0364; E-mail [email protected].
Department of Emergency Medicine University of Florida Health Science Center
47/1/109212 doi:10.1067/mem.2000.109212
Jacksonville, FL Address for reprints: Robert L. Wears, MD, MS, Department of Emergency Jacksonville, FL 32209; 904-549-4124, 904-549-4508; E-mail [email protected].
Emergency Departments and Uninsured Children: An Enrollment Opportunity
47/1/109692
Susan M. Nedza, MD
doi:10.1067/mem.2000.109692
Chair, Legislative and Regulatory Committee
Medicine, University of Florida Health Science Center, 655 West 8th Street,
American College of Emergency Physicians
Easier Breathing?
Irving, TX
Rita K. Cydulka, MD
Deborah Mulligan-Smith, MD
Department of Emergency Medicine
Committee on Pediatrics
MetroHealth Medical Center
American College of Emergency Physicians
Case Western Reserve University
Irving, TX
Cleveland, OH
Russell Harris, MD
Reprints not available from the author. Address for correspondence: Rita K. Cydulka, MD, Department of Emergency Medicine, MetroHealth Medical Center, Room S1-203, Cleveland, OH 44109; 216-778-5088; E-mail [email protected].
Immediate Past-President New Jersey Chapter American College of Emergency Physicians Trenton, NJ Address for reprints: Susan M. Nedza, MD, Department of Emergency
47/1/109687 doi:10.1067/mem.2000.109687
Medicine, Elmhurst Memorial Hospital, 200 Berteau, Elmhurst, IL 60126; fax 630-986-9443; E-mail [email protected].
The Prudent Layperson Definition: Will It Work for Emergency Medicine?
47/1/109448 doi:10.1067/mem.2000.109448 Copyright © 2000 by the American College of Emergency Physicians.
Robert M. Williams, MD, DrPH
0196-0644/2000/$12.00 + 0
Department of Health Management and Policy University of Michigan School of Public Health Ann Arbor, MI
SEPTEMBER 2000
36:3
ANNALS OF EMERGENCY MEDICINE
2 3 3
EDITORIALS
spective of emergency physicians, other sectors of the health care system are unlikely to reach the same conclusions as the authors. From a health policy perspective, the real value of this study is that it clearly demonstrates that the prudent layperson approach, although arguably a start in the right direction, is seriously flawed as a reliable method of assigning patient levels of urgency in the ED. The authors report an interevaluator agreement rate between 2 emergency physicians who evaluated the same sample of charts as 80%. Although this is pretty good, put another way, 2 physicians from the same institution could not accurately agree on 1 patient in 5 with regard to meeting the prudent layperson standard. How much greater would be the disagreement among evaluators who represent the MCO plan? What if nonphysicians were used to make the determination of compliance with the standard? As long as the validation process of who qualifies under the prudent layperson definition is based on subjective criteria, there will always be legitimate and intense dispute over whose definition is correct. As in the past, emergency physicians will push for inclusive criteria, while managed care organizations will promote exclusive standards. In summary, the prudent layperson definition can serve as a method of certifying a level of urgency sufficient to warrant emergency services. Because the method is inherently based on subjective criteria, however, the widespread implementation of such a plan would likely be met with intense opposition, with key players promoting their own subjective interpretation of the certification criteria. To be an effective and acceptable policy mechanism, the prudent layperson definition must be expanded in practical terms to include a more accurate and verifiable group of criteria. And this requirement for objectivity rather than subjectivity is the crux of the problem for policymakers, patients, insurance companies, and emergency physicians. The trick, of course, is trying to get agreement among disparate and conflicting groups of stakeholders as to the correct set of explicit and objective criteria. 1. Shesser R, Holtermann K, Smith J, et al. Results of provider self-adjudication using the prudent layperson standard compared with the managed care organization’s emergency department claim review process. Ann Emerg Med. 2000;36:212-218. 2. Lee S, Solon J, Sheps C. How new patterns of medical care affect the emergency unit. Mod Hosp. 1960;94:97-101. 3. Weinerman ER, Ratner RS, Robbins A, et al. Yale studies in ambulatory care. Determinants of use of hospital emergency services. Am J Public Nations Health. 1966;56:1037-1056. 4. Jacobs AR, Gavett JW, Wersinger R. Emergency department utilization in the urban community. Implications for community ambulatory care. JAMA. 1971;216:307-312. 5. Roth JA. Utilization of the hospital emergency department. J Health Soc Behav. 1971;12:312320.
2 4 0
6. Vayda E, Gent M, Hendershot A. Emergency department use at two Hamilton hospitals. Can Med Assoc J. 1975;112:961-965. 7. Gifford MJ, Franaszek JB, Gibson G. Emergency physicians’ and patients’ assessments: urgency of need for medical care. Ann Emerg Med. 1980;9:502-507. 8. Fleming NS, Jones HC. The impact of outpatient department and emergency room use on costs in the Texas Medicaid Program. Med Care. 1983;21:892-910. 9. Dickhudt JS, Gjerdingen Dk, Asp DS. Emergency room use and abuse. How it varies with payment mechanism. Minn Med. 1987;70:571-574. 10. Parboosingh EJ, Larsen DE. Factors influencing frequency and appropriateness of utilization of the emergency room by the elderly. Med Care. 1987;25:1139-1147. 11. Singal BM, Hedges JR, Rousseau EW, et al. Geriatric patient emergency visits. Part I: comparison of visits by geriatric and younger patients. Ann Emerg Med. 1992;21:802-807. 12. Inspector General, Department of Health and Human Services. Controlling emergency room use: state Medicaid reports 1992 [OEI publication 06-90-00181]. Washington, DC: Department of Health and Human Services; 1992. 13. General Accounting Office. Report to the Chairman, Subcommittee on Health for Families and the Uninsured, Committee on Finance, US Senate Emergency Departments: Unevenly Affected by Growth and Change in Patient Use 1993 [publication No. GAO/HRD-93-4]. Washington, DC, General Accounting Office; 1993. 14. Mitchell TA, Remmel RJ. Level of uncompensated care delivered by emergency physicians in Florida. Ann Emerg Med. 1992;21:1208-1214. 15. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: projections from a multicenter data base. Ann Emerg Med. 1992;21:819-824. 16. Williams RM. The costs of visits to emergency departments [letter]. N Engl J Med. 1996;335:209-210. 17. McCaig LF. National Hospital Ambulatory Medical Care Survey: 1992 emergency department summary. Advance data from Vital and Health Statistics; no 245. Hyattsville, MD: National Center for Health Statistics; 1994. 18. Wallston BS, Wallston KA. Social psychological models of health behavior: an examination and integration, in Baum A, Taylor S, Singer J, eds. Handbook of Psychology and Health. Hillsdale, NJ: Lawrence Erlbaum Assocates; 1984. 19. Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q. 1984;11:1-47. 20. Suls J. Social support, interpersonal relations, and health: denefits and liabilities, in Sanders GS, Suls J, eds. Social Psychology and of Health and Illness. Hillsdale, NJ: Lawrence Erlbaum Associates; 1982. 21. Brillman JC, Doezema D, Tandberg D, et al. Triage: limitations in predicting need for emergent care and hospital admission. Ann Emerg Med. 1996;27:493-500.
Emergency Departments and Uninsured Children: An Enrollment Opportunity [Nedza SM, Mulligan-Smith D, Harris R. Emergency departments and uninsured children: an enrollment opportunity. Ann Emerg Med. September 2000;36:240-242.] Even though America’s economic health has never been better, an uninsured population that is growing at an alarming rate jeopardizes its physical health. The call from citizens, providers, and elected officials for solutions to this problem and to provide access to care continues to grow. Coverage for the uninsured is critically important to emergency departments, as the only site required by law to screen and stabilize all who seek emer-
ANNALS OF EMERGENCY MEDICINE
36:3 SEPTEMBER 2000
EDITORIALS
gency care under the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986.1 As the one site where uninsured individuals are guaranteed access to the health care system under this statute, EDs play a vital role as part of the safety net by caring for uninsured children and their families. This is substantiated by the fact that EDs provided care to 16,388,736 individuals without health care coverage from a total of 97 million visits in 1996.2 As the percentage of uninsured ED visits increases, what is an appropriate role for emergency medicine in addressing this complex issue? Should EDs solely be limited to complying with the EMTALA legal mandate to provide emergency care? Or should the role be expanded to seeking collaborative enrollment solutions and access to primary care for these individuals? Ultimately, are EDs part of the problem (expensive sites of care that are to be avoided at all cost), or are they part of a comprehensive solution? We postulate that these departments have a unique opportunity to join patient enrollment programs that are seeking to improve access to care for the uninsured. The most promising opportunity is through efforts to enroll children in the State Children’s Health Insurance Program (SCHIP). This program is one of the most significant health care reforms for children since the enactment of Medicaid in 1965. Under Title XXI, the federal government allocated to the states more than $24 billion between 1998 and 2002, and nearly $40 billion over the 10-year life of the legislation, to provide health insurance for previously uninsured children. States were given broad latitude to create a program that specifically addressed the needs within that state. To receive funding, each state plan was required to maintain the Medicaid eligibility in place on April 15, 1997, and maintain the same level of state spending on child health programs that was expended in 1996. Initially, few states developed comprehensive plans. Most elected to participate by implementing Medicaid expansions while they continued to work on a more comprehensive plan. To assist in this effort, the federal government passed several modifications to Medicaid law, allowing for a more streamlined eligibility and enrollment process. During 1999, more and more states went beyond Medicaid expansion and began to develop comprehensive SCHIP programs. By mid-1999, every state and territory had an approved plan operating within its jurisdiction. However, new program development constraints slowed enrollment in SCHIP during the first 6 to 9 months after
SEPTEMBER 2000
36:3
ANNALS OF EMERGENCY MEDICINE
enactment and prompted some to criticize the program and call for its repeal. However, during the last half of 1998, the new systems began to have an impact, resulting in health care coverage for 1 million previously uninsured children. Efforts to seek new strategies to increase enrollment are accelerating, although access and enrollment problems continue. These problems were reflected in a recent report, “The Kaiser Commission on Medicaid and the Uninsured,”3 that recognized 2 significant barriers to the success of this program. The first is that families with no previous connection to the welfare system must be informed about the SCHIP program and that their children may be eligible. The second is that the enrollment systems must be instituted with minimal administrative burden. The Kaiser report also supports efforts to distribute outreach materials widely so that they reach all segments of the targeted population. These outreach strategies need to be community-based, and in many cases one-onone. It is in this area that EDs can play a vital role in ensuring the success of these efforts. We suggest that an effort that is currently under way in New Jersey could provide a method for other EDs to follow and to refine. The New Jersey Chapter of the American College of Emergency Physicians is the 550-member specialty association representing physicians practicing in the state’s EDs. They have successfully partnered with NJ Kidcare4 to undertake enrollment strategies. The program began with an educational piece that was distributed to all member physicians within the state. Information about the plan was also highlighted in the chapter newsletter. To support enrollment, the chapter disseminated materials describing the program and eligibility EDs throughout the state. This information is available in both Spanish and English. The brochures also carefully address the issue of the eligibility of the children of undocumented aliens. In addition, a toll-free (800) telephone number for information is also posted in the waiting rooms. Further collaboration occurred when the NJ KidCare staff also established enrollment sites on evenings and weekends in targeted EDs. The heightened awareness of the program led to an additional benefit as registration personnel also began encouraging families to enroll their children. A concerted effort was made to maintain communication among the chapter, NJ KidCare, medical staffs, and hospital administrations. The chapter also encouraged that state administrators be kept informed on changes in the program.
2 4 1
EDITORIALS
Initially, New Jersey officials estimated that 350,000 children were without health insurance within the state. Since the program began, they have successfully enrolled 60,000 of the 154,00 children eligible for SCHIP. How much of this success has been directly linked to EDs? Although outreach materials continue to be disseminated through these sites, there is currently no tracking mechanism to directly measure the number of new enrollees attributable to this project. Clearly, this needs to be monitored as the effort continues and should be included in any other state efforts. This lack of definitive data does not diminish the potential of using these locations as a point of access to target eligible families and children for SCHIPS enrollment. One of the hurdles to implementing this type of effort is the great variability of resources from institution to institution. No single model will be successful. Institutions can seek customized solutions ranging from the simple placement of basic information in waiting rooms to the active use of social workers to facilitate enrollment of children. Institutions may also consider other enrollment strategies such as using discharge information in their efforts. Finally, including information in bills sent to patients who identify themselves as self-payers may be the appropriate incentive needed to encourage enrollment. As the states move toward models of presumed eligibility, we postulate that ED outreach in the area of enrollment will also become easier. EDs have a vital role in providing care and access to the health care system in every community. EDs are also uniquely positioned to undertake this effort. It has been estimated that a patient spends 147 minutes in an ED during the average visit. Of this time, only 28 minutes is direct care time.5 On a fundamental level, this should be considered a unique teachable moment. This non–direct care time provides a window of opportunity to reach this group with the message of available coverage options such as SCHIPS or Medicaid. Will this effort work? The US Department of Health and Human Services actively promotes the importance of having health insurance and recognizes that a regular source of continuing care leads to healthier outcomes.6 It might be argued that improving access to insurance is only a small part of the work necessary to improve the health of the population. It remains to be seen if this program or others like it actually lead to better health. More specifically, it is impossible to say whether enrollment in the SCHIPS program will decrease ED utilization for nonurgent care or increase reimbursement. Until these questions can be answered, emergency
2 4 2
medicine can look on this as an opportunity to define itself as an important voice and potential partner in efforts to incrementally increase access to health care. Hopefully, we will then be perceived as part of the solution to the problem of the uninsured and not excluded from policy initiatives as part of the problem. 1. Health Care Financing Administration. The Emergency Medical Treatment and Active Labor Act, as established under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 USC 1395 dd). Federal Register. 1994;59:32086-32127. 2. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 Emergency Department Summary. NCHS Advance Data No. 293, Center for Disease Control, National Center for Health Statistics. Hyattsville, MD: National Center for Health Statistics; December 1997. 3. Making Child Health Coverage a Reality: Lessons From Case Studies of Medicaid and CHIP Outreach and Enrollment Strategies. Kaiser Commission on Medicaid and the Uninsured. Menlo Park, CA: Henry J. Kaiser Family Foundation; September 1999. 4. NJ Kidcare FAQ. Available at: http://www.njkidcare.org. Accessed July 11, 2000. 5. Emergency Care Reform, Executive Briefing for Clinical Leaders. Washington, DC: Clinical Initiatives Center, the Advisory Board Company; 1998. 6. Simpson G, Bloom B. Access to Health Care Part 1: Children, Vital and Health Statistics, Series 10 (National Health Survey No. 196). Hyattsville, MD: National Center for Health Statistics; 1997.
ANNALS OF EMERGENCY MEDICINE
36:3 SEPTEMBER 2000
Dueling Meta-Analyses
Address for reprints: Robert M. Williams MD, DrPH, School of Public Health, University of Michigan, 1420 Washington Heights, Ann Arbor, MI 48109-2029;
Robert L. Wears, MD, MS
231-938-2494, fax 231-938-0364; E-mail [email protected].
Department of Emergency Medicine University of Florida Health Science Center
47/1/109212 doi:10.1067/mem.2000.109212
Jacksonville, FL Address for reprints: Robert L. Wears, MD, MS, Department of Emergency Jacksonville, FL 32209; 904-549-4124, 904-549-4508; E-mail [email protected].
Emergency Departments and Uninsured Children: An Enrollment Opportunity
47/1/109692
Susan M. Nedza, MD
doi:10.1067/mem.2000.109692
Chair, Legislative and Regulatory Committee
Medicine, University of Florida Health Science Center, 655 West 8th Street,
American College of Emergency Physicians
Easier Breathing?
Irving, TX
Rita K. Cydulka, MD
Deborah Mulligan-Smith, MD
Department of Emergency Medicine
Committee on Pediatrics
MetroHealth Medical Center
American College of Emergency Physicians
Case Western Reserve University
Irving, TX
Cleveland, OH
Russell Harris, MD
Reprints not available from the author. Address for correspondence: Rita K. Cydulka, MD, Department of Emergency Medicine, MetroHealth Medical Center, Room S1-203, Cleveland, OH 44109; 216-778-5088; E-mail [email protected].
Immediate Past-President New Jersey Chapter American College of Emergency Physicians Trenton, NJ Address for reprints: Susan M. Nedza, MD, Department of Emergency
47/1/109687 doi:10.1067/mem.2000.109687
Medicine, Elmhurst Memorial Hospital, 200 Berteau, Elmhurst, IL 60126; fax 630-986-9443; E-mail [email protected].
The Prudent Layperson Definition: Will It Work for Emergency Medicine?
47/1/109448 doi:10.1067/mem.2000.109448 Copyright © 2000 by the American College of Emergency Physicians.
Robert M. Williams, MD, DrPH
0196-0644/2000/$12.00 + 0
Department of Health Management and Policy University of Michigan School of Public Health Ann Arbor, MI
SEPTEMBER 2000
36:3
ANNALS OF EMERGENCY MEDICINE
2 3 3
EDITORIALS
spective of emergency physicians, other sectors of the health care system are unlikely to reach the same conclusions as the authors. From a health policy perspective, the real value of this study is that it clearly demonstrates that the prudent layperson approach, although arguably a start in the right direction, is seriously flawed as a reliable method of assigning patient levels of urgency in the ED. The authors report an interevaluator agreement rate between 2 emergency physicians who evaluated the same sample of charts as 80%. Although this is pretty good, put another way, 2 physicians from the same institution could not accurately agree on 1 patient in 5 with regard to meeting the prudent layperson standard. How much greater would be the disagreement among evaluators who represent the MCO plan? What if nonphysicians were used to make the determination of compliance with the standard? As long as the validation process of who qualifies under the prudent layperson definition is based on subjective criteria, there will always be legitimate and intense dispute over whose definition is correct. As in the past, emergency physicians will push for inclusive criteria, while managed care organizations will promote exclusive standards. In summary, the prudent layperson definition can serve as a method of certifying a level of urgency sufficient to warrant emergency services. Because the method is inherently based on subjective criteria, however, the widespread implementation of such a plan would likely be met with intense opposition, with key players promoting their own subjective interpretation of the certification criteria. To be an effective and acceptable policy mechanism, the prudent layperson definition must be expanded in practical terms to include a more accurate and verifiable group of criteria. And this requirement for objectivity rather than subjectivity is the crux of the problem for policymakers, patients, insurance companies, and emergency physicians. The trick, of course, is trying to get agreement among disparate and conflicting groups of stakeholders as to the correct set of explicit and objective criteria. 1. Shesser R, Holtermann K, Smith J, et al. Results of provider self-adjudication using the prudent layperson standard compared with the managed care organization’s emergency department claim review process. Ann Emerg Med. 2000;36:212-218. 2. Lee S, Solon J, Sheps C. How new patterns of medical care affect the emergency unit. Mod Hosp. 1960;94:97-101. 3. Weinerman ER, Ratner RS, Robbins A, et al. Yale studies in ambulatory care. Determinants of use of hospital emergency services. Am J Public Nations Health. 1966;56:1037-1056. 4. Jacobs AR, Gavett JW, Wersinger R. Emergency department utilization in the urban community. Implications for community ambulatory care. JAMA. 1971;216:307-312. 5. Roth JA. Utilization of the hospital emergency department. J Health Soc Behav. 1971;12:312320.
2 4 0
6. Vayda E, Gent M, Hendershot A. Emergency department use at two Hamilton hospitals. Can Med Assoc J. 1975;112:961-965. 7. Gifford MJ, Franaszek JB, Gibson G. Emergency physicians’ and patients’ assessments: urgency of need for medical care. Ann Emerg Med. 1980;9:502-507. 8. Fleming NS, Jones HC. The impact of outpatient department and emergency room use on costs in the Texas Medicaid Program. Med Care. 1983;21:892-910. 9. Dickhudt JS, Gjerdingen Dk, Asp DS. Emergency room use and abuse. How it varies with payment mechanism. Minn Med. 1987;70:571-574. 10. Parboosingh EJ, Larsen DE. Factors influencing frequency and appropriateness of utilization of the emergency room by the elderly. Med Care. 1987;25:1139-1147. 11. Singal BM, Hedges JR, Rousseau EW, et al. Geriatric patient emergency visits. Part I: comparison of visits by geriatric and younger patients. Ann Emerg Med. 1992;21:802-807. 12. Inspector General, Department of Health and Human Services. Controlling emergency room use: state Medicaid reports 1992 [OEI publication 06-90-00181]. Washington, DC: Department of Health and Human Services; 1992. 13. General Accounting Office. Report to the Chairman, Subcommittee on Health for Families and the Uninsured, Committee on Finance, US Senate Emergency Departments: Unevenly Affected by Growth and Change in Patient Use 1993 [publication No. GAO/HRD-93-4]. Washington, DC, General Accounting Office; 1993. 14. Mitchell TA, Remmel RJ. Level of uncompensated care delivered by emergency physicians in Florida. Ann Emerg Med. 1992;21:1208-1214. 15. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: projections from a multicenter data base. Ann Emerg Med. 1992;21:819-824. 16. Williams RM. The costs of visits to emergency departments [letter]. N Engl J Med. 1996;335:209-210. 17. McCaig LF. National Hospital Ambulatory Medical Care Survey: 1992 emergency department summary. Advance data from Vital and Health Statistics; no 245. Hyattsville, MD: National Center for Health Statistics; 1994. 18. Wallston BS, Wallston KA. Social psychological models of health behavior: an examination and integration, in Baum A, Taylor S, Singer J, eds. Handbook of Psychology and Health. Hillsdale, NJ: Lawrence Erlbaum Assocates; 1984. 19. Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q. 1984;11:1-47. 20. Suls J. Social support, interpersonal relations, and health: denefits and liabilities, in Sanders GS, Suls J, eds. Social Psychology and of Health and Illness. Hillsdale, NJ: Lawrence Erlbaum Associates; 1982. 21. Brillman JC, Doezema D, Tandberg D, et al. Triage: limitations in predicting need for emergent care and hospital admission. Ann Emerg Med. 1996;27:493-500.
Emergency Departments and Uninsured Children: An Enrollment Opportunity [Nedza SM, Mulligan-Smith D, Harris R. Emergency departments and uninsured children: an enrollment opportunity. Ann Emerg Med. September 2000;36:240-242.] Even though America’s economic health has never been better, an uninsured population that is growing at an alarming rate jeopardizes its physical health. The call from citizens, providers, and elected officials for solutions to this problem and to provide access to care continues to grow. Coverage for the uninsured is critically important to emergency departments, as the only site required by law to screen and stabilize all who seek emer-
ANNALS OF EMERGENCY MEDICINE
36:3 SEPTEMBER 2000
EDITORIALS
gency care under the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986.1 As the one site where uninsured individuals are guaranteed access to the health care system under this statute, EDs play a vital role as part of the safety net by caring for uninsured children and their families. This is substantiated by the fact that EDs provided care to 16,388,736 individuals without health care coverage from a total of 97 million visits in 1996.2 As the percentage of uninsured ED visits increases, what is an appropriate role for emergency medicine in addressing this complex issue? Should EDs solely be limited to complying with the EMTALA legal mandate to provide emergency care? Or should the role be expanded to seeking collaborative enrollment solutions and access to primary care for these individuals? Ultimately, are EDs part of the problem (expensive sites of care that are to be avoided at all cost), or are they part of a comprehensive solution? We postulate that these departments have a unique opportunity to join patient enrollment programs that are seeking to improve access to care for the uninsured. The most promising opportunity is through efforts to enroll children in the State Children’s Health Insurance Program (SCHIP). This program is one of the most significant health care reforms for children since the enactment of Medicaid in 1965. Under Title XXI, the federal government allocated to the states more than $24 billion between 1998 and 2002, and nearly $40 billion over the 10-year life of the legislation, to provide health insurance for previously uninsured children. States were given broad latitude to create a program that specifically addressed the needs within that state. To receive funding, each state plan was required to maintain the Medicaid eligibility in place on April 15, 1997, and maintain the same level of state spending on child health programs that was expended in 1996. Initially, few states developed comprehensive plans. Most elected to participate by implementing Medicaid expansions while they continued to work on a more comprehensive plan. To assist in this effort, the federal government passed several modifications to Medicaid law, allowing for a more streamlined eligibility and enrollment process. During 1999, more and more states went beyond Medicaid expansion and began to develop comprehensive SCHIP programs. By mid-1999, every state and territory had an approved plan operating within its jurisdiction. However, new program development constraints slowed enrollment in SCHIP during the first 6 to 9 months after
SEPTEMBER 2000
36:3
ANNALS OF EMERGENCY MEDICINE
enactment and prompted some to criticize the program and call for its repeal. However, during the last half of 1998, the new systems began to have an impact, resulting in health care coverage for 1 million previously uninsured children. Efforts to seek new strategies to increase enrollment are accelerating, although access and enrollment problems continue. These problems were reflected in a recent report, “The Kaiser Commission on Medicaid and the Uninsured,”3 that recognized 2 significant barriers to the success of this program. The first is that families with no previous connection to the welfare system must be informed about the SCHIP program and that their children may be eligible. The second is that the enrollment systems must be instituted with minimal administrative burden. The Kaiser report also supports efforts to distribute outreach materials widely so that they reach all segments of the targeted population. These outreach strategies need to be community-based, and in many cases one-onone. It is in this area that EDs can play a vital role in ensuring the success of these efforts. We suggest that an effort that is currently under way in New Jersey could provide a method for other EDs to follow and to refine. The New Jersey Chapter of the American College of Emergency Physicians is the 550-member specialty association representing physicians practicing in the state’s EDs. They have successfully partnered with NJ Kidcare4 to undertake enrollment strategies. The program began with an educational piece that was distributed to all member physicians within the state. Information about the plan was also highlighted in the chapter newsletter. To support enrollment, the chapter disseminated materials describing the program and eligibility EDs throughout the state. This information is available in both Spanish and English. The brochures also carefully address the issue of the eligibility of the children of undocumented aliens. In addition, a toll-free (800) telephone number for information is also posted in the waiting rooms. Further collaboration occurred when the NJ KidCare staff also established enrollment sites on evenings and weekends in targeted EDs. The heightened awareness of the program led to an additional benefit as registration personnel also began encouraging families to enroll their children. A concerted effort was made to maintain communication among the chapter, NJ KidCare, medical staffs, and hospital administrations. The chapter also encouraged that state administrators be kept informed on changes in the program.
2 4 1
EDITORIALS
Initially, New Jersey officials estimated that 350,000 children were without health insurance within the state. Since the program began, they have successfully enrolled 60,000 of the 154,00 children eligible for SCHIP. How much of this success has been directly linked to EDs? Although outreach materials continue to be disseminated through these sites, there is currently no tracking mechanism to directly measure the number of new enrollees attributable to this project. Clearly, this needs to be monitored as the effort continues and should be included in any other state efforts. This lack of definitive data does not diminish the potential of using these locations as a point of access to target eligible families and children for SCHIPS enrollment. One of the hurdles to implementing this type of effort is the great variability of resources from institution to institution. No single model will be successful. Institutions can seek customized solutions ranging from the simple placement of basic information in waiting rooms to the active use of social workers to facilitate enrollment of children. Institutions may also consider other enrollment strategies such as using discharge information in their efforts. Finally, including information in bills sent to patients who identify themselves as self-payers may be the appropriate incentive needed to encourage enrollment. As the states move toward models of presumed eligibility, we postulate that ED outreach in the area of enrollment will also become easier. EDs have a vital role in providing care and access to the health care system in every community. EDs are also uniquely positioned to undertake this effort. It has been estimated that a patient spends 147 minutes in an ED during the average visit. Of this time, only 28 minutes is direct care time.5 On a fundamental level, this should be considered a unique teachable moment. This non–direct care time provides a window of opportunity to reach this group with the message of available coverage options such as SCHIPS or Medicaid. Will this effort work? The US Department of Health and Human Services actively promotes the importance of having health insurance and recognizes that a regular source of continuing care leads to healthier outcomes.6 It might be argued that improving access to insurance is only a small part of the work necessary to improve the health of the population. It remains to be seen if this program or others like it actually lead to better health. More specifically, it is impossible to say whether enrollment in the SCHIPS program will decrease ED utilization for nonurgent care or increase reimbursement. Until these questions can be answered, emergency
2 4 2
medicine can look on this as an opportunity to define itself as an important voice and potential partner in efforts to incrementally increase access to health care. Hopefully, we will then be perceived as part of the solution to the problem of the uninsured and not excluded from policy initiatives as part of the problem. 1. Health Care Financing Administration. The Emergency Medical Treatment and Active Labor Act, as established under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 USC 1395 dd). Federal Register. 1994;59:32086-32127. 2. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 Emergency Department Summary. NCHS Advance Data No. 293, Center for Disease Control, National Center for Health Statistics. Hyattsville, MD: National Center for Health Statistics; December 1997. 3. Making Child Health Coverage a Reality: Lessons From Case Studies of Medicaid and CHIP Outreach and Enrollment Strategies. Kaiser Commission on Medicaid and the Uninsured. Menlo Park, CA: Henry J. Kaiser Family Foundation; September 1999. 4. NJ Kidcare FAQ. Available at: http://www.njkidcare.org. Accessed July 11, 2000. 5. Emergency Care Reform, Executive Briefing for Clinical Leaders. Washington, DC: Clinical Initiatives Center, the Advisory Board Company; 1998. 6. Simpson G, Bloom B. Access to Health Care Part 1: Children, Vital and Health Statistics, Series 10 (National Health Survey No. 196). Hyattsville, MD: National Center for Health Statistics; 1997.
ANNALS OF EMERGENCY MEDICINE
36:3 SEPTEMBER 2000