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Are uninsured traumas at a greater risk?
Likely causes for disparity in death rates
A study published in the November 2009 issue of the Archives of Surgery1 has caused a stir in ED circles by asserting that uninsured trauma patients are more likely to die than those patients who have insurance. While the study did not come to any conclusions about the cause for this apparent disparity, the authors offered possible explanations, including those patients experience more delays due to multiple transfers, they have greater difficulty communicating with doctors, and they receive different care.
On the latter point, of course, ED managers say clearly that they treat all patients the same. Some experts, however, concede that you should not rule out the possibility of unconscious biases. "Several things may be at play that cause these individuals to have poorer care and recovery rates," notes Sandra M. Schneider, MD, FACEP, president-elect of the American College of Emergency Physicians and professor of emergency medicine at the University of Rochester (NY). "They may be reluctant to seek care even when injured. Many come in with conditions that are not well treated, like diabetes or high blood pressure, which can make recovery worse. Or they may be reluctant to have expensive tests."
However, she adds, "Studies like this make us examine ourselves to see if there is any bias we're not aware of. We all have some kind of unconscious bias somewhere. That's the importance of this article."
The researchers reviewed nearly 700,000 patients from the National Trauma Data Bank, and they definitely found some disparities for uninsured patients, says Jeffrey S. Dubin, MD, vice chair of the Department of Emergency Medicine, Washington (DC) Hospital Center. "It's really surprising from an emergency department standpoint because with major traumas, everything is done for these patients without any thought to cost — at least for initial treatment," he says. "No one checks your insurance if you need a CAT scan."
However, Dubin says, "If anything, for the ED staff it's just a reminder that perhaps even without thinking about it, there may be some subconscious bias that exists and reflect on that, so that all care decisions for the patient are made without regard to cost or insurance."
Eric Lavonas, MD, an emergency physician for Denver Health Medical Center, says the study's findings are provocative and demand to be answered. "The authors chose a good database and used it well. They've measured differences in outcome and tried to speculate on why this is so," Lavonas says. "They offer a series of well thought-out, educated guesses, but this paper cannot tell which of those three is contributing and how much." In addition, he says, "I've never worked in a place where we rationed tests that were necessary."
Lavonas adds that "usually you order tests even before they ask for an insurance card, so you usually don't know [if the patient is insured]. The theory is that we act differently based on information we not have."
He says it's more likely the answer lies in the other options noted by the authors: Patients are transferred when it could be avoided, or they have comorbidities that are not in the record or previously diagnosed.
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Be proactive with uninsured patients
While ED managers and their staffs were not identified as the "bad guys" by the authors of a recent study showing uninsured trauma patients had higher mortality rates than those with insurance, emergency medicine experts agree there are proactive steps ED managers can take to try to offset this disparity.
First, you can address whatever biases might exist within the staff, says Sandra M. Schneider, MD, FACEP, president-elect of the American College of Emergency Physicians and professor of emergency medicine at the University of Rochester (NY). "Keep your eyes and ears open for any evidence of bias where people express concerns about whether or not patients can pay for treatments," Schneider says.
Many ED physicians intentionally don't look at a patient's insurance status, she says. "I myself say I never look at it because it keeps me from being biased," shares Schneider, adding that it would be a "very good idea" for the ED manager to encourage the whole staff to do the same.
In addition, she says, when the patients volunteer that they are uninsured, "I would work hard to get these people insured. Many of them actually qualify for government programs. For example, some veterans do not even know they are entitled to care, while others might be encouraged to apply for Medicaid."
Many uninsured patients do not speak English, notes Jeff Dubin, MD, vice chair of the Department of Emergency Medicine, Washington (DC) Hospital Center. In such cases, "If language assistance is needed, make sure it happens," he says.
In addition, Dubin says, use all available sources of information, including old records, and be creative." If a patient is on one or more medications, "a very good strategy is to ask where they get the meds filled, and with the patient's permission, call the pharmacy and get all the meds they're on," he says. With this strategy, you might find out they were on blood pressure medicine six months ago and had not refilled the prescription, he says.
Standard work a two-edged sword
"Standard work" can be a force for evil or good in the care of trauma patients, says Eric Lavonas, MD, an emergency physician for Denver Health Medical Center.
"Several studies have shown that standardized laboratory or X-ray panels for trauma patients result in overordering and overexposure to radiation without improving diagnostic accuracy," he notes. "However, if you can get your physician and nursing teams to agree on a few ground rules, things generally will go a lot more smoothly."
For example, he says, have your physicians to agree on one combination of drugs to use for intubation and post-intubation sedation most of the time. "This combination won't be appropriate for every patient, but 90% of the time, you can reduce errors by making a complex task routine," Lavonas explains. The key is to strike a balance, he says. Have a consistent approach, but be comfortable departing from it when there's a clear reason to do so.