ORIGINAL CONTRIBUTION
em.ergency department, use indigency, medical
Level of Uncompensated Care Delivered by Emergency Physicians in Florida From the Department of Internal Medicine, College of Medicine;* and the Information Systems and Decision Sciences Department, College of Business Administration,t University of South Florida, Tampa.
Toni A Mitchell, MD, MBA, FACEP*
S t u d y objectives: To determine selected characteristics of patients
Randall J Remmel, PhD, MBAt
who present for care in emergency departments in Florida, the proportion who appear to be uninsured or underinsured, and the magnitude of uncompensated care provided by the emergency physicians in selected EDs in Florida.
Receivedfor publication August 30, 1991. Revision received March 2, 1992. Acceptedfor publication April 13, 1992.
Design: Retrospective analysis of billing data. Setting:
Twenty-five EOs in Florida.
M a i n results: Uninsured patients comprised 20.6% of the sample. Emergency and urgent patients were 39.9% of the sample. The overall collection ratio was 59.2%. Conclusion: Emergency physicians provide substantial amounts of uncompensated care. [Mitchell TA, Remmel RJ: Level of uncompensated care delivered by emergency physicians in Florida. Ann EmergMed October 1992;21:1208-1214.] INTRODUCTION The provision of health care has undergone many changes in the past decade, including the introduction of diagnosisrelated groups and the rise of managed health care. More change is anticipated with the implementation of the resourcebased relative value scale and the application of diagnosisrelated groups to outpatient services. These recent initiatives have focused primarily on the cost of health care. In 1970 health care costs consumed about 3.8% of the gross national product, but that had risen to approximately 11% in 1988. During that same time the u n i n s u r e d proportion of the population grew from approximately 11.3% to the present 15%. 1 Demographic information on these u n i n s u r e d patients indicated that many were employed and earned incomes above the official federal poverty level, and approximately one third were u n d e r the age of 18 years. Therefore, it has been difficult to define "indigent" care with precision. Earher studies have comprised and included those who are either u n i n s u r e d or unable t o p a y . 2,3 Present estimates indicate that approximately 35 million people have no insurance coverage, and an additional 15 million are underinsured. 4 Because most physicians expect
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payment at the time of service, many of these patients seek care at the facility of last r e s o r t - - h o s p i t a l EDs. 5 Statistics from the American Hospital Association support these findings because ED usage per capita increased 550% between 1955 and 1980, while hospital admission rates p e r capita only increased 30% and visits to doctors' offices remained unchanged. 6 ED visits in 1986 were an estimated 87 million, which increased to 97 million in 1987. 4 Insurance companies have traditionally p a i d for visits to EDs but not visits to doctors' offices. So patients may seek treatment for a nouemergency problem at an ED so that their insurance will pay for treatment. One study also indicated that "persons in the lower third of the income distribution had emergency d e p a r t m e n t expenses that were 66 percent higher than those of persons in the u p p e r t h i r d of the income distribution. ''6 Certain socioeconomic groups use the ED for virtually all their health care needs. This may reflect their lack of access to more traditional sources of health care and that these patients may tend to delay seeking care until they are much sicker.7, 8 Although a number of studies have evaluated the amount of uncompensated care provided by hospitals 2,6,9,10 only two studies have included a physician component.11,12 These studies were limited somewhat by the methodology used, because only physicians in fee-for-service practices were interviewed specifically about uncompensated care. In the first study, the value of uncompensated care (charity and b a d debts) provided by nearly 340,000 patient care physicians (excluding residents) in 1982 was about $9.2 billion. 11 A more recent study determined the amounts of charity care, b a d debt, and discounted Medicaid care provided by a sample of group practices in Wisconsin. 12 In this setting the physicians provided $20,900 yearly p e r physician or approximately 7.6% of total billings for the year. No emergency physicians were included in either survey because they are traditionally independent contractors with hospitals, and before 1986 the physician's fee was usually billed by the hospital. The amount of uncompensated care provided by emergency physicians would a p p e a r to be substantial because of the large numbers of uninsured and u n d e r i n s u r e d patients who present to the ED for care.2, ~ Therefore, this exploratory study was designed to attempt to determine who the patients are, how many a p p e a r to be uninsured or underinsured, and the magnitude of uncompensated care provided by the emergency physicians in selected EDs in Florida. MATERIALS
AND
METHODS
Billing activities on behalf of emergency physicians may be carried out by the physician group, by the hospital, by an independent billing firm, or by each individual physician. A magnetic tape containing billing data for 45,005 patients was obtained from a well-known medical billing firm that specializes in billing for emergency physicians. This firm has billed emergency visits since 1978. In 1990 it billed more than
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2 million visits (130 hospitals). The firm assigns diagnosis codes based on information contained in the medical chart, bills p r i m a r y and all secondary insurance carriers, and balance bills the patient. The study patients presented to 33 hospital EDs in May 1989. Twenty-five of these hospitals are located in Florida. All geographic areas of the state are represented, and aH physicians are Medicare "participating" physicians. Each of these EDs treats up to 40,000 patients p e r year. Private fol~ profit, private nonprofit, and public hospitals were represented. However, data for the state's four Level I trauma centers, which treat large numbers of uninsured patients, were not available. Although this was a limitation of the study, it ensures that the results presented are conservative. To reduce the computing resources and manual data gathering r e q u i r e d for this exploratory study, every 20th patient record on the magnetic tape was t r a n s f e r r e d to magnetic disk. This systematic sampling technique is appropriate because the d a t a set was not sorted in a manner that would be expected to yield an unrepresentative sample. The records from hospitals outside F l o r i d a then were discarded. The remaining 1,645 records were put into the SAS programs used to calculate summary statistics. This sample size is a p p r o p r i a t e for estimating a population p r o p o r t i o n to within 0.025 with a probability of .95.
Table 1. Descriptive statistics--Socioeconomic data
No. of Patients %
Collection Ratio Mean
Adjustment Ratio Mean
Bad Debt Ratio Mean
Age (yr) 0-5 6-18 19-29 30-39 40-49 50-64 > 64
192 239 364 269 146 152 293
11.7 14.5 22.1 15.7 8.9 9.2 17.8
0,568 0.599 0.495 0.494 0.606 0.703 0.730
0.099 0.068 0,076 0.090 0.060 0.086 0.210
0.313 0.333 0,429 0,416 0.334 0.211 0.060
307 31 1,172
20.3 2.1 77.6
0.475 0.523 0.632
0.105 0.044 0.098
0.420 0.433 0.270
808 835
49.2 50.8
0.595 0,595
0,105 0.101
0,300 0.310
593 623
48.8 51.2
0.628 0.551
0.093 0.125
0.279 0.324
28 656 312 11 147
2.4 56.8 27.0 1.0 12,7
0.478 0.562 0,721 0.702 0,488
0.168 0,078 0.202 0,048 0.083
0.354 0.360 0.077 0.250 0,429
Race Black Other White
Gender Female Male
Marital Status (age >17 yr) Married Unmarried
Employment Status (age >17 yr) Disabled Employed Retired Student Not employed
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The billing data contained in each record included the hospital number, date of service, patient number, p r i m a r y responsible party code (self-responsible, Medicare, Medicaid, commercial insurance, p r e p a i d plan, or workers compensation), the total amount charged by the emergency physician, the total amount collected from all sources, the total amount of adjustments made by all insurance carriers, and the amount remaining uncollected after 12 months. Also included were the Current P r o c e d u r a l Terminology-4 (CPT) codes and diagnosis codes (ICD-9) used to determine the charges to be billed for the visit. Because socioeconomic data are not p a r t of a patient's billing record, such data were obtained for these 1,645 patient visits during a site visit to the billing firm. Each of the required paper records was located, and the age, race, gender, employment status, and marital status were recorded. The collection ratio, adjustment ratio, and b a d debt ratio were calculated as follows. The collection ratio is the amount collected by the billing firm from all sources within 12 months of the patient visit divided by the total physician's charges for the visit. The adjustment ratio is the total amount of adjustments made by all insurance carriers divided by the total physician's charges for the visit. The b a d debt ratio is the amount judged by the billing firm to be uncollectible (ie, written off) after 12 months divided by the total physician's charges for the visit. The first CPT code (brief, limited, intermediate, extended, comprehensive, complex, or other) was used in this study. The primary ICD-9 code was used to determine whether the patient's visit to the ED was due p r i m a r i l y to an illness or an injury and whether the acuity of the visit was emergency, urgent, semiurgent, or nonurgent, as determined by the discharge diagnosis. The 432 ICD-9 codes used for these 1,645 patients were evaluated by a panel of five practicing b o a r d certified emergency physicians. Each member of the panel assigned an illness/injury value (ill or injured) and an acuity value (emergency, urgent, semiurgent, or nonurgent) to each ICD-9 code. The value assigned to each ICD-9 code was
agreed to by at least three of the five panel physicians. Agreement among the panel physicians was 100% (all five panelists agreed) for 33.9% of the ICD-9 codes, 80% (one panelist did not agree) for 27.2% of the codes, and 60% (two panelists did not agree) for 38.9 % of the codes. The definitions used by the panel physicians to assign an acuity value to discharge diagnoses (ICD-9 codes) were as follows. • Emergency: patient who requires immediate treatment; life- or limb-threatening conditions • Urgent: patient who requires medical attention within an hour and has the potential to become an emergency if left unattended • Semiurgent: patient who is stable at the time of assessment and is unlikely to deteriorate within two to three hours • Nonurgent: patient whose condition is not acute and is in no obvious distress RESULTS
The age distribution of the 1,645 patients is shown (Table 1) (percentages do not equal 100% because of rounding). Data indicating the race and gender of each patient were available for 1,510 patients and 1,643 patients, respectively (Table 1). Data indicating the marital status and employment status of patients 18 years of age or older were available for 1,216 patients and 1,154 patients, respectively. These data are presented (Table 1) (percentages do not sum to 100% because of rounding). The p r i m a r y responsible p a r t y data are shown (Table 2). Those patients without insurance coverage of any kind, private or public, were considered self-responsible. Automobile insurance coverage is included with commercial insurance. Medicaid reimbursement in Florida is based on a fee schedule.
Table 3. Descriptive statistics
Medical data
No. of Patients %
Table 2. Descriptive statistics--Primary responsible party
Collection Ratio Mean
Adjustment Ratio Mean
Bad Debt Ratio Mean
Primary CPT Code Collection Ratio Mean
Adjustment Ratio Mean
Bad Debt Ratio Mean
20.6 17.5 7.3 32.0
0.277 0.675 0,601 0.659
0,006 0,250 0,299 0.014
0.717 0,075 0.100 0,327
14.5
0.778
0,071
0.151
8.1
0.602
0.265
0.133
No. of Patients % PrimaryInsurance Self-responsible 339 Medicare 288 Medicaid 120 Commercial 526 Healthmaintenance organization/ preferred provider organization 238 Workers compensation 134
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Brief (new) Limited Intermediate Extended Comprehensive Brief(established) Other Illness/Injury Injured Illness Acuity Emergency Urgent Semiurgent Nonurgent
26 375 644 197 159 124 130
t.6 22.8 39.1 11.4 9.7 7.5 7.9
0.636 0.557 0.580 0,610 0,686 0.556 0.634
0.190 0.094 0.096 0.137 0.107 0,113 0,085
0.174 0,349 0.324 0,253 0,207 0.331 0.281
663 977
40.4 59.6
0.589 0.595
0.101 0,104
0.310 0.301
230 425 906 79
14.0 25,9 55.2 4.8
0,617 0.626 0,574 0.549
0,116 0.115 0.095 0.100
0.267 0,259 0,331 0,351
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The first CPT code was considered because it may reflect the acuity of the level of service. The most commonly used values of the code are termed brief, limited, intermediate, extended, comprehensive, and critical care. CPT codes are available for procedures (such as suturing) as well as the level of service. Most visits were either limited or intermediate, as shown (Table 3). These level-of-service codes may be combined with p r o c e d u r a l codes as well, but only the first CPT code was used for purposes of our analysis. More intensive care is reflected in the extended and comprehensive designations because these generally represent patients who are admitted to the hospital and/or observed in the ED for an extended period. ICD-9 codes were available for 1,640 patients. Patients who presented to the ED because of illness comprised 59.6% of the patients, and 40.4% were i n j u r e d (Table 3). The numbers of emergency, urgent, semiurgent, and nonurgent patients also a p p e a r (Table 3) (percentages do not equal 100% because of rounding). Collection, adjustment, and b a d debt ratios exhibited by the sample for age, employment status, p r i m a r y responsible party, first CPT code, and acuity variables are shown (Figures 1 through 5). Means associated with these ratios are reported (Tables 1, 2, and 3). Collections were highest for those patients older than 64 years and lowest for the 19-to29-year and 30-to-39-year age groups (Figure 1). The collection ratio for white patients was somewhat higher than for others. Gender and m a r i t a l status (patients aged 18 years and older) had httle impact on collection ratio. Data for employment status (patients aged 18 years and older) show that disabled patients and those not employed provide the lowest collection ratio and retired persons provide the highest (Figure 2).
Self-responsible patients (Table 2) had a very low collection ratio (27.7%). Higher ratios were observed for Medicare, health maintenance organization/preferred p r o v i d e r organization, and commercial insurance (Figure 3). Note that the billing f i n n negotiates the health maintenance organization and p r e f e r r e d provider organization contracts on behalf of the emergency groups practicing in the hospitals included in this study. The collection ratios for the most common CPT codes (Figure 4) indicated a higher percentage for patients in the extended and comprehensive groups, with lower ratios for the limited and intermediate. Brief visits for new patients resulted in a higher collection ratio than estabhshed patients. The collection ratios for ill and injured patients were similar. The collection ratios for emergency, urgent, semiurgent, and nonurgent patients generally decreased as the acuity decreased (Figure 5). The o v e r a l l collection r a t i o for the sample was 59.2%. Total charges for the 1,645 p a t i e n t s a m o u n t e d to $153,781, which e x t r a p o l a t e s to $36.9 million a n n u a l l y for t o t a l billings for the EDs i n c l u d e d in this study. Based on this collection r a t i o , $21.8 million was a c t u a l l y collected, a n d $15.1 million was a d j u s t e d or w r i t t e n off. The EDs i n c l u d e d in this study employ an average of 4.36 full-time e q u i v a l e n t emergency p h y s i c i a n s . Thus, an average of $103,700 p e r p h y s i c i a n r e m a i n e d uncollected after one year. Adjustments were highest for those patients older than 64 years of age (Table 1). All other age groups exhibited much lower ratios. The adjustment ratio did not vary greatly by race, gender, marital status (patients aged 18 years and older), or employment status (patients aged 18 years and
Figure 1.
Figure 2. Reiumbursment by employment status of patient (adults)
Reimburs ment by age of patient Proportion of Charges
Proportion of Charges 1,0-0.9-0.8-0.7-0.6-0,5-0,4--
0.3 f 0.2 0.1
0 to 15
6t018 []
56/1211
19 to 29
Collected
30 tO 39 40 to 49 50 to 64 65 & Older Age (yr) ~ Adjusted [ ] Written Off
0.0
Disabled ]
Employed NotEmployed Retired Student Employment Status Collected Adjusted [ ] Written Off
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older). Medicare, Medicaid, and workers compensation patients had the highest ratios, and sell-responsible and health maintenance organizations/preferred provider organizations had the lowest (Table 2). Again, the billing firm negotiates the health maintenance organization and preferred provider organization contracts on behalf of the emergency groups. The adjustment ratios for the most common CPT codes (Table 3) indicated higher ratios for brief visits for new patients than for limited, intermediate, comprehensive, and brief visits by established patients. The adjustment ratios for ill and injured patients were almost the same. Those for emergency, urgent, semiurgent, and nonurgent patients also were similar. Bad debts were highest for those patients in the 19-to-29year and 30-to-39-year age groups (Table 1). The ratio for white patients was lower than for other groups. Gender and marital status (patients aged 18 years and older) had minimal impact on bad debt ratio. Data for employment status (patients aged 18 years and older) show that those not employed represent the highest bad debt ratio, and retired persons are the lowest. Self-responsible patients (Table 2) had a very high bad debt ratio (71.7%). Patients with commercial insurance had a bad debt ratio about haft as high. Lower ratios were observed for Medicaid, Medicare, workers compensation, and health maintenance organization/preferred provider organization. The bad debt ratios for the most common CPT codes indicated higher ratios for patients in the limited, intermediate, and brief established categories than for patients with brief (new patient), extended, and comprehensive visits (Table 3).
The state of Florida has traditionally had very- stringent guidelines for Medicaid. To qualify-, a family must not exceed 100% of federal poverty guidelines for that year. As a result, very few low-income families qualified. For the study year, there was a ceiling of 45 days of coverage for inpatient services and $1,000 for outpatient services. Some improvements have been made recently, particularly in covering pregnant women and children. But only 700,000 people are eligible for Medicaid by Florida guidelines. 13 Another significant problem contributing to the indigent care load is the preponderance of small businesses operating in Florida. In 1989 it was estimated that 90% of Florida companies have fewer than ten employees, and research indicates that 40% of these companies do not provide health insurance for their employeesJ 3 The problem of adequate coverage is made worse by the general disarray of county public health departments caused by poor funding, aging facilities, and low esteem of public health agencies in the eyes of the public. Data from this study indicate that most patients who present to hospital EDs are employed or retired (implying previ-
Figure 3.
Figure 4.
The bad debt ratios for ill and injured patients were similar. The ratios for emergency, urgent, semiurgent, and nonurgent patients generally increased as acuity decreased. Patients who paid nothing at all to the emergency physician comprised 26.1% of the sample (429 patients). Of selfresponsible patients, 66.7% paid nothing. For patients whose primary responsible party was commercial insurance, 24.9% of the accounts had nothing paid by any party after 12 months.
BISCUSSl0N
Reimbursment by primary responsible party of patient Proportion of Charges
Reiumburs merit by first CPT code I I
i
1.0
Proportion of Charges
! 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1
SelfMedicare Medicaid Commercial HMO/PPO Workers Responsible Compensation Primary Responsible Party • Collected Adjusted [ ] Written Off
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0.0
Brief (new) •
Limited Intermediate Extended Comprehensive Brief Other (established) Primary Responsible Party Collected Adjusted [ ] Written Off
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ous employment), white, and young (younger than 40 years of age). Most (79.4%) are covered by some insurance, but 20.6% are not. The age breakdown is interesting, because all children younger than the age of 18 years are ehgible for Medicaid in Florida. Presumably this explains the collection ratio of nearly 60% for this age group. The largest single age group (19 to 29 years) contributing 22.1% of the visits represents a collection ratio of 49.5%. Similarly, the 30-to-39-year age group has a collection ratio of 49.4%. Presumably most of these people are employed but most likely in jobs without adequate insurance coverage. Further, this group is also the most likely to be affected by accidents and injuries that may require emergency treatment. 4 The age groups of 40 to 64 years rarely use the ED for their health care needs. These groups, taken together, account for only 18.1% of the patient visits. Perhaps this is a reflection of the greater likelihood of employment, higher level positions within a company, and adequate insurance coverage. They may seek health care through their doctor's office or a walk-in clinic. After age 64 years most patients will be retired and covered by Medicare and/or additional private insurance. This is reflected in the higher collection ratio of 73%. Their increased use of the ED is more likely a reflection of their increased frequency and severity of illness. The percentage Of patients by race showed a preponderance of whites (77.6%) versus blacks (20.3%). These numbers might differ somewhat if the Level I trauma centers in Miami, Jacksonville, Orlando, and Tampa were included° because ED populations are generally a reflection of the racial mix of the surrounding population. 14 Data were not available from these facilities, however.
Figure 5. Reiumbursment by acuity of patient Proportion of Charges 1,0-0.9 0.8-0.7-0.6-0.5-0.4-0.3-0.2 -0.1-0 . 0 - -
Emergent •
58/1213
Collected
Urgent
Semiurgent Acuity • Adjusted
Nonurgent Written Off
Retired persons are generally well insured, and this is reflected in the higher collection ratio of 72.1%. Employed adults exhibited a 56.2% collection ratio, which probably is indicative of the large n u m b e r of employed, uninsured patients in our patient population. Disabled persons exhibit a collection ratio of 47.8%, which is even lower than for adults who were not employed (48.8%). Many disabled patients qualify for Medicaid when they are initially disabled. But once these patients begin to receive Social Security Disability Income, they exceed the Medicaid guidelines for the state of Florida and so no longer receive benefits. When classified by first CPT code, 21% of the ED visits were extended or comprehensive. Most of these patients likely required admission to the hospital or at least prolonged observation in the ED itself. The remaining patients were less critical, although the visit may have been justified because we did not consider procedure codes along with level of service codes. So the severity of lacerations or fractures, which have both types of codes, may be underestimated. Forty percent of the visits were thought to be emergency or urgent based on discharge diagnosis, supporting the need for acute care in the ED. More patients present for evaluation of illnesses than injuries, although workers compensation patients will be heavily weighted toward the i n j u r y category. Other studies have indicated that injuries are higher in some age groups, so the predominance of i n j u r y versus illness varies from age group to age group. 4 Insurers seem more willing to reimburse for those patients with serious illnesses or injuries because the collection ratios for extended and comprehensive visits were higher than those for intermediate and limited visits. These collection ratios show a similar relationship with severity of illness, because they are higher for emergency and urgent conditions than semiurgent and nonurgent ones. However, it should be noted that adjustments were substantial for such government-funded programs as Medicare, Medicaid, and workers compensation. These ratios were not affected by severity of illness, injury, or level of care provided. Physicians who evaluate large numbers of Medicaid patients may have substantial uncollectible amounts because of these adjustments. At present, collections are reasonable for Medicare patients, but as pressures increase to contain spending, the level of adjustments could accelerate and materially affect this ratio. Actual write-offs because of bad debt were highest among the patients who were identified as self-responsible and were concentrated in the 19-to-39-year age group. Although patients who were not employed were more likely to fall in this group, the percentage (42.9%) was not as different from employed (36.0%) as might be expected. As previously mentioned, many of these patients may be employed by businesses that do not provide health care insurance. In addition, many men in this age group who are unemployed may not be
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eligible for Medicaid in the same p r o p o r t i o n as unemployed women. Bad debt tended to be higher in the less urgent patients, probably because these patients use the ED as their family physician. This is further supported by the higher b a d debt ratios for brief, limited, and intermediate CPT treatment codes. Also, seriously ill or injured patients may subsequently qualify-for some medical coverage (county funded, Medicaid, Medicare). Two thirds of self-responsible patients never made any payments after 12 months. This result might be anticipated. But surprisingly, almost one q u a r t e r of patients with commercial insurance also paid nothing for services provided. Most of these patients are either employed, dependents of someone who is employed, or victims of automobile accidents. [nsurance coverage may be inadequate to cover some illnesses or injuries, so the patient chooses to pay nothing either. Each emergency physician in this study provided approximately $103,700 of uncompensated and discounted care to patients presenting to their EDs in 1988. This compares favorably with the $20,900 provided by group practice physicians in Wisconsin in 1988.12 The discrepancy is likely due to the higher number of Medicaid and uninsured patients seen in emergency settings. Limitations of this study are largely related to the lack of data from Florida's four Level I t r a u m a centers. However, this omission p r o b a b l y tends to cause the p r o p o r t i o n of uninsured patients and the amount of uncompensated care to be underestimated. The results presented herein are, therefore, conservative.
REFERENCES 1. Inglehart JK: Medical care of the poor-A growing problem. IVEnglJMed 1985;313:59-63. 2. Melnick GA, Mann J, 6elan I: Uncompensated emergency care in hospital markets in Los Angeles County. Am J Pubfic Health 1989;79:514-516. 3. Lewin LS, Eckles TJ, Miller LB: The provision of uncompensated care by not-for-profit hospitals. N Engl J Med1988;318:1212-1215. 4.6reene J: Trauma in the emergency department. Modem Health Care 1988;18:28-33. 5. Podolsky ML: Patients, providers, and payers. Private Practice 1988;20:23-28. 6. O'6rady KF, Manning W6, Newhouse J, et al: The impact of cost sharing on emergency department use. N Engl J Mef11985;313:484-490. 7. Weissman JS, Stern R, Fielding SL, et al: Delayed access to health care: Risk factors, reasons, and consequences. Ann Intern Med1991;114:325-331. 8. Epstein A, Stern R, Tognetti J, et al: The association of patients' socioeconomic characteristics with the length of stay and hospital charges within diagnosis-related groups. N Engl J Med 1988;318:1579-1585. 9. Schiff RL, Ansell DA, Schlosser JE, et ah Transfers to a public hospital: A prospective study of 467 patients. N Engl J Med 1986;314:552-557. 10. Rice MF: Equity issues in inner city hospital care: Patient dumping, emergency care, and public policy. J Health Hum Resaurc Adm 1988;10:289-296. 11.0hsfeldt RL: Uncompensated medical services provided by physicians and hospitals. Med Care 1988;23:1338-1344. 12. Durham NO, Kindig DA, Lastiri-Quiros S, et al: Uncompensated and discounted Medicaid care provided by physician group practices in Wisconsin. JAMA 1991;265:2982-2986. 13. Koenig J: No more running from indigent care. Florida Trend1989;32:21-23. 14. Torrens PR, Yedvab DG: Variations among emergency room populations: A comparison of four hospitals in New York City. Med Care 1970;8:60-75. The authors thank Gettlieb's Financial Services, Jacksonville, Florida, for their assistance with data collection. They also thank Stephen J Dresnick, MD, FACEP, for helpful comments.
CONCLUSION
Significant policy implications are a p p a r e n t from this study regarding proposed changes in reimbursement and improved access to health care. The emergency physicians in this study participated in Medicaid and accepted assignment for Medicare patients for 100% of claims submitted. A comparison from Health Care Financing Administration data for 1987 supplied to the American College of Emergency Physicians indicates that 91.2% of Medicare services were provided on assignment (personal communication, J u d y Young, ACEP). The results of this study indicate that emergency physicians contribute significantly toward the care of all patients who are critically ill, severely injured, or simply have no other place to go for care. Serious consideration must be given to the magnitude of "free" care currently given to self-responsible patients by proponents of universal health care. F u r t h e r cuts in the level of reimbursement from government agencies could begin to compromise both the quality and availability of care to the very groups the programs are designed to protect.
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Address for reprints: Toni A Mitchell, MD, MBA, FACEP The Emergency Associates for Medicine 4 Columbia Drive, Suite 810 Tampa, Florida 33606
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em.ergency department, use indigency, medical
Level of Uncompensated Care Delivered by Emergency Physicians in Florida From the Department of Internal Medicine, College of Medicine;* and the Information Systems and Decision Sciences Department, College of Business Administration,t University of South Florida, Tampa.
Toni A Mitchell, MD, MBA, FACEP*
S t u d y objectives: To determine selected characteristics of patients
Randall J Remmel, PhD, MBAt
who present for care in emergency departments in Florida, the proportion who appear to be uninsured or underinsured, and the magnitude of uncompensated care provided by the emergency physicians in selected EDs in Florida.
Receivedfor publication August 30, 1991. Revision received March 2, 1992. Acceptedfor publication April 13, 1992.
Design: Retrospective analysis of billing data. Setting:
Twenty-five EOs in Florida.
M a i n results: Uninsured patients comprised 20.6% of the sample. Emergency and urgent patients were 39.9% of the sample. The overall collection ratio was 59.2%. Conclusion: Emergency physicians provide substantial amounts of uncompensated care. [Mitchell TA, Remmel RJ: Level of uncompensated care delivered by emergency physicians in Florida. Ann EmergMed October 1992;21:1208-1214.] INTRODUCTION The provision of health care has undergone many changes in the past decade, including the introduction of diagnosisrelated groups and the rise of managed health care. More change is anticipated with the implementation of the resourcebased relative value scale and the application of diagnosisrelated groups to outpatient services. These recent initiatives have focused primarily on the cost of health care. In 1970 health care costs consumed about 3.8% of the gross national product, but that had risen to approximately 11% in 1988. During that same time the u n i n s u r e d proportion of the population grew from approximately 11.3% to the present 15%. 1 Demographic information on these u n i n s u r e d patients indicated that many were employed and earned incomes above the official federal poverty level, and approximately one third were u n d e r the age of 18 years. Therefore, it has been difficult to define "indigent" care with precision. Earher studies have comprised and included those who are either u n i n s u r e d or unable t o p a y . 2,3 Present estimates indicate that approximately 35 million people have no insurance coverage, and an additional 15 million are underinsured. 4 Because most physicians expect
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payment at the time of service, many of these patients seek care at the facility of last r e s o r t - - h o s p i t a l EDs. 5 Statistics from the American Hospital Association support these findings because ED usage per capita increased 550% between 1955 and 1980, while hospital admission rates p e r capita only increased 30% and visits to doctors' offices remained unchanged. 6 ED visits in 1986 were an estimated 87 million, which increased to 97 million in 1987. 4 Insurance companies have traditionally p a i d for visits to EDs but not visits to doctors' offices. So patients may seek treatment for a nouemergency problem at an ED so that their insurance will pay for treatment. One study also indicated that "persons in the lower third of the income distribution had emergency d e p a r t m e n t expenses that were 66 percent higher than those of persons in the u p p e r t h i r d of the income distribution. ''6 Certain socioeconomic groups use the ED for virtually all their health care needs. This may reflect their lack of access to more traditional sources of health care and that these patients may tend to delay seeking care until they are much sicker.7, 8 Although a number of studies have evaluated the amount of uncompensated care provided by hospitals 2,6,9,10 only two studies have included a physician component.11,12 These studies were limited somewhat by the methodology used, because only physicians in fee-for-service practices were interviewed specifically about uncompensated care. In the first study, the value of uncompensated care (charity and b a d debts) provided by nearly 340,000 patient care physicians (excluding residents) in 1982 was about $9.2 billion. 11 A more recent study determined the amounts of charity care, b a d debt, and discounted Medicaid care provided by a sample of group practices in Wisconsin. 12 In this setting the physicians provided $20,900 yearly p e r physician or approximately 7.6% of total billings for the year. No emergency physicians were included in either survey because they are traditionally independent contractors with hospitals, and before 1986 the physician's fee was usually billed by the hospital. The amount of uncompensated care provided by emergency physicians would a p p e a r to be substantial because of the large numbers of uninsured and u n d e r i n s u r e d patients who present to the ED for care.2, ~ Therefore, this exploratory study was designed to attempt to determine who the patients are, how many a p p e a r to be uninsured or underinsured, and the magnitude of uncompensated care provided by the emergency physicians in selected EDs in Florida. MATERIALS
AND
METHODS
Billing activities on behalf of emergency physicians may be carried out by the physician group, by the hospital, by an independent billing firm, or by each individual physician. A magnetic tape containing billing data for 45,005 patients was obtained from a well-known medical billing firm that specializes in billing for emergency physicians. This firm has billed emergency visits since 1978. In 1990 it billed more than
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2 million visits (130 hospitals). The firm assigns diagnosis codes based on information contained in the medical chart, bills p r i m a r y and all secondary insurance carriers, and balance bills the patient. The study patients presented to 33 hospital EDs in May 1989. Twenty-five of these hospitals are located in Florida. All geographic areas of the state are represented, and aH physicians are Medicare "participating" physicians. Each of these EDs treats up to 40,000 patients p e r year. Private fol~ profit, private nonprofit, and public hospitals were represented. However, data for the state's four Level I trauma centers, which treat large numbers of uninsured patients, were not available. Although this was a limitation of the study, it ensures that the results presented are conservative. To reduce the computing resources and manual data gathering r e q u i r e d for this exploratory study, every 20th patient record on the magnetic tape was t r a n s f e r r e d to magnetic disk. This systematic sampling technique is appropriate because the d a t a set was not sorted in a manner that would be expected to yield an unrepresentative sample. The records from hospitals outside F l o r i d a then were discarded. The remaining 1,645 records were put into the SAS programs used to calculate summary statistics. This sample size is a p p r o p r i a t e for estimating a population p r o p o r t i o n to within 0.025 with a probability of .95.
Table 1. Descriptive statistics--Socioeconomic data
No. of Patients %
Collection Ratio Mean
Adjustment Ratio Mean
Bad Debt Ratio Mean
Age (yr) 0-5 6-18 19-29 30-39 40-49 50-64 > 64
192 239 364 269 146 152 293
11.7 14.5 22.1 15.7 8.9 9.2 17.8
0,568 0.599 0.495 0.494 0.606 0.703 0.730
0.099 0.068 0,076 0.090 0.060 0.086 0.210
0.313 0.333 0,429 0,416 0.334 0.211 0.060
307 31 1,172
20.3 2.1 77.6
0.475 0.523 0.632
0.105 0.044 0.098
0.420 0.433 0.270
808 835
49.2 50.8
0.595 0,595
0,105 0.101
0,300 0.310
593 623
48.8 51.2
0.628 0.551
0.093 0.125
0.279 0.324
28 656 312 11 147
2.4 56.8 27.0 1.0 12,7
0.478 0.562 0,721 0.702 0,488
0.168 0,078 0.202 0,048 0.083
0.354 0.360 0.077 0.250 0,429
Race Black Other White
Gender Female Male
Marital Status (age >17 yr) Married Unmarried
Employment Status (age >17 yr) Disabled Employed Retired Student Not employed
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The billing data contained in each record included the hospital number, date of service, patient number, p r i m a r y responsible party code (self-responsible, Medicare, Medicaid, commercial insurance, p r e p a i d plan, or workers compensation), the total amount charged by the emergency physician, the total amount collected from all sources, the total amount of adjustments made by all insurance carriers, and the amount remaining uncollected after 12 months. Also included were the Current P r o c e d u r a l Terminology-4 (CPT) codes and diagnosis codes (ICD-9) used to determine the charges to be billed for the visit. Because socioeconomic data are not p a r t of a patient's billing record, such data were obtained for these 1,645 patient visits during a site visit to the billing firm. Each of the required paper records was located, and the age, race, gender, employment status, and marital status were recorded. The collection ratio, adjustment ratio, and b a d debt ratio were calculated as follows. The collection ratio is the amount collected by the billing firm from all sources within 12 months of the patient visit divided by the total physician's charges for the visit. The adjustment ratio is the total amount of adjustments made by all insurance carriers divided by the total physician's charges for the visit. The b a d debt ratio is the amount judged by the billing firm to be uncollectible (ie, written off) after 12 months divided by the total physician's charges for the visit. The first CPT code (brief, limited, intermediate, extended, comprehensive, complex, or other) was used in this study. The primary ICD-9 code was used to determine whether the patient's visit to the ED was due p r i m a r i l y to an illness or an injury and whether the acuity of the visit was emergency, urgent, semiurgent, or nonurgent, as determined by the discharge diagnosis. The 432 ICD-9 codes used for these 1,645 patients were evaluated by a panel of five practicing b o a r d certified emergency physicians. Each member of the panel assigned an illness/injury value (ill or injured) and an acuity value (emergency, urgent, semiurgent, or nonurgent) to each ICD-9 code. The value assigned to each ICD-9 code was
agreed to by at least three of the five panel physicians. Agreement among the panel physicians was 100% (all five panelists agreed) for 33.9% of the ICD-9 codes, 80% (one panelist did not agree) for 27.2% of the codes, and 60% (two panelists did not agree) for 38.9 % of the codes. The definitions used by the panel physicians to assign an acuity value to discharge diagnoses (ICD-9 codes) were as follows. • Emergency: patient who requires immediate treatment; life- or limb-threatening conditions • Urgent: patient who requires medical attention within an hour and has the potential to become an emergency if left unattended • Semiurgent: patient who is stable at the time of assessment and is unlikely to deteriorate within two to three hours • Nonurgent: patient whose condition is not acute and is in no obvious distress RESULTS
The age distribution of the 1,645 patients is shown (Table 1) (percentages do not equal 100% because of rounding). Data indicating the race and gender of each patient were available for 1,510 patients and 1,643 patients, respectively (Table 1). Data indicating the marital status and employment status of patients 18 years of age or older were available for 1,216 patients and 1,154 patients, respectively. These data are presented (Table 1) (percentages do not sum to 100% because of rounding). The p r i m a r y responsible p a r t y data are shown (Table 2). Those patients without insurance coverage of any kind, private or public, were considered self-responsible. Automobile insurance coverage is included with commercial insurance. Medicaid reimbursement in Florida is based on a fee schedule.
Table 3. Descriptive statistics
Medical data
No. of Patients %
Table 2. Descriptive statistics--Primary responsible party
Collection Ratio Mean
Adjustment Ratio Mean
Bad Debt Ratio Mean
Primary CPT Code Collection Ratio Mean
Adjustment Ratio Mean
Bad Debt Ratio Mean
20.6 17.5 7.3 32.0
0.277 0.675 0,601 0.659
0,006 0,250 0,299 0.014
0.717 0,075 0.100 0,327
14.5
0.778
0,071
0.151
8.1
0.602
0.265
0.133
No. of Patients % PrimaryInsurance Self-responsible 339 Medicare 288 Medicaid 120 Commercial 526 Healthmaintenance organization/ preferred provider organization 238 Workers compensation 134
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Brief (new) Limited Intermediate Extended Comprehensive Brief(established) Other Illness/Injury Injured Illness Acuity Emergency Urgent Semiurgent Nonurgent
26 375 644 197 159 124 130
t.6 22.8 39.1 11.4 9.7 7.5 7.9
0.636 0.557 0.580 0,610 0,686 0.556 0.634
0.190 0.094 0.096 0.137 0.107 0,113 0,085
0.174 0,349 0.324 0,253 0,207 0.331 0.281
663 977
40.4 59.6
0.589 0.595
0.101 0,104
0.310 0.301
230 425 906 79
14.0 25,9 55.2 4.8
0,617 0.626 0,574 0.549
0,116 0.115 0.095 0.100
0.267 0,259 0,331 0,351
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The first CPT code was considered because it may reflect the acuity of the level of service. The most commonly used values of the code are termed brief, limited, intermediate, extended, comprehensive, and critical care. CPT codes are available for procedures (such as suturing) as well as the level of service. Most visits were either limited or intermediate, as shown (Table 3). These level-of-service codes may be combined with p r o c e d u r a l codes as well, but only the first CPT code was used for purposes of our analysis. More intensive care is reflected in the extended and comprehensive designations because these generally represent patients who are admitted to the hospital and/or observed in the ED for an extended period. ICD-9 codes were available for 1,640 patients. Patients who presented to the ED because of illness comprised 59.6% of the patients, and 40.4% were i n j u r e d (Table 3). The numbers of emergency, urgent, semiurgent, and nonurgent patients also a p p e a r (Table 3) (percentages do not equal 100% because of rounding). Collection, adjustment, and b a d debt ratios exhibited by the sample for age, employment status, p r i m a r y responsible party, first CPT code, and acuity variables are shown (Figures 1 through 5). Means associated with these ratios are reported (Tables 1, 2, and 3). Collections were highest for those patients older than 64 years and lowest for the 19-to29-year and 30-to-39-year age groups (Figure 1). The collection ratio for white patients was somewhat higher than for others. Gender and m a r i t a l status (patients aged 18 years and older) had httle impact on collection ratio. Data for employment status (patients aged 18 years and older) show that disabled patients and those not employed provide the lowest collection ratio and retired persons provide the highest (Figure 2).
Self-responsible patients (Table 2) had a very low collection ratio (27.7%). Higher ratios were observed for Medicare, health maintenance organization/preferred p r o v i d e r organization, and commercial insurance (Figure 3). Note that the billing f i n n negotiates the health maintenance organization and p r e f e r r e d provider organization contracts on behalf of the emergency groups practicing in the hospitals included in this study. The collection ratios for the most common CPT codes (Figure 4) indicated a higher percentage for patients in the extended and comprehensive groups, with lower ratios for the limited and intermediate. Brief visits for new patients resulted in a higher collection ratio than estabhshed patients. The collection ratios for ill and injured patients were similar. The collection ratios for emergency, urgent, semiurgent, and nonurgent patients generally decreased as the acuity decreased (Figure 5). The o v e r a l l collection r a t i o for the sample was 59.2%. Total charges for the 1,645 p a t i e n t s a m o u n t e d to $153,781, which e x t r a p o l a t e s to $36.9 million a n n u a l l y for t o t a l billings for the EDs i n c l u d e d in this study. Based on this collection r a t i o , $21.8 million was a c t u a l l y collected, a n d $15.1 million was a d j u s t e d or w r i t t e n off. The EDs i n c l u d e d in this study employ an average of 4.36 full-time e q u i v a l e n t emergency p h y s i c i a n s . Thus, an average of $103,700 p e r p h y s i c i a n r e m a i n e d uncollected after one year. Adjustments were highest for those patients older than 64 years of age (Table 1). All other age groups exhibited much lower ratios. The adjustment ratio did not vary greatly by race, gender, marital status (patients aged 18 years and older), or employment status (patients aged 18 years and
Figure 1.
Figure 2. Reiumbursment by employment status of patient (adults)
Reimburs ment by age of patient Proportion of Charges
Proportion of Charges 1,0-0.9-0.8-0.7-0.6-0,5-0,4--
0.3 f 0.2 0.1
0 to 15
6t018 []
56/1211
19 to 29
Collected
30 tO 39 40 to 49 50 to 64 65 & Older Age (yr) ~ Adjusted [ ] Written Off
0.0
Disabled ]
Employed NotEmployed Retired Student Employment Status Collected Adjusted [ ] Written Off
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older). Medicare, Medicaid, and workers compensation patients had the highest ratios, and sell-responsible and health maintenance organizations/preferred provider organizations had the lowest (Table 2). Again, the billing firm negotiates the health maintenance organization and preferred provider organization contracts on behalf of the emergency groups. The adjustment ratios for the most common CPT codes (Table 3) indicated higher ratios for brief visits for new patients than for limited, intermediate, comprehensive, and brief visits by established patients. The adjustment ratios for ill and injured patients were almost the same. Those for emergency, urgent, semiurgent, and nonurgent patients also were similar. Bad debts were highest for those patients in the 19-to-29year and 30-to-39-year age groups (Table 1). The ratio for white patients was lower than for other groups. Gender and marital status (patients aged 18 years and older) had minimal impact on bad debt ratio. Data for employment status (patients aged 18 years and older) show that those not employed represent the highest bad debt ratio, and retired persons are the lowest. Self-responsible patients (Table 2) had a very high bad debt ratio (71.7%). Patients with commercial insurance had a bad debt ratio about haft as high. Lower ratios were observed for Medicaid, Medicare, workers compensation, and health maintenance organization/preferred provider organization. The bad debt ratios for the most common CPT codes indicated higher ratios for patients in the limited, intermediate, and brief established categories than for patients with brief (new patient), extended, and comprehensive visits (Table 3).
The state of Florida has traditionally had very- stringent guidelines for Medicaid. To qualify-, a family must not exceed 100% of federal poverty guidelines for that year. As a result, very few low-income families qualified. For the study year, there was a ceiling of 45 days of coverage for inpatient services and $1,000 for outpatient services. Some improvements have been made recently, particularly in covering pregnant women and children. But only 700,000 people are eligible for Medicaid by Florida guidelines. 13 Another significant problem contributing to the indigent care load is the preponderance of small businesses operating in Florida. In 1989 it was estimated that 90% of Florida companies have fewer than ten employees, and research indicates that 40% of these companies do not provide health insurance for their employeesJ 3 The problem of adequate coverage is made worse by the general disarray of county public health departments caused by poor funding, aging facilities, and low esteem of public health agencies in the eyes of the public. Data from this study indicate that most patients who present to hospital EDs are employed or retired (implying previ-
Figure 3.
Figure 4.
The bad debt ratios for ill and injured patients were similar. The ratios for emergency, urgent, semiurgent, and nonurgent patients generally increased as acuity decreased. Patients who paid nothing at all to the emergency physician comprised 26.1% of the sample (429 patients). Of selfresponsible patients, 66.7% paid nothing. For patients whose primary responsible party was commercial insurance, 24.9% of the accounts had nothing paid by any party after 12 months.
BISCUSSl0N
Reimbursment by primary responsible party of patient Proportion of Charges
Reiumburs merit by first CPT code I I
i
1.0
Proportion of Charges
! 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1
SelfMedicare Medicaid Commercial HMO/PPO Workers Responsible Compensation Primary Responsible Party • Collected Adjusted [ ] Written Off
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0.0
Brief (new) •
Limited Intermediate Extended Comprehensive Brief Other (established) Primary Responsible Party Collected Adjusted [ ] Written Off
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ous employment), white, and young (younger than 40 years of age). Most (79.4%) are covered by some insurance, but 20.6% are not. The age breakdown is interesting, because all children younger than the age of 18 years are ehgible for Medicaid in Florida. Presumably this explains the collection ratio of nearly 60% for this age group. The largest single age group (19 to 29 years) contributing 22.1% of the visits represents a collection ratio of 49.5%. Similarly, the 30-to-39-year age group has a collection ratio of 49.4%. Presumably most of these people are employed but most likely in jobs without adequate insurance coverage. Further, this group is also the most likely to be affected by accidents and injuries that may require emergency treatment. 4 The age groups of 40 to 64 years rarely use the ED for their health care needs. These groups, taken together, account for only 18.1% of the patient visits. Perhaps this is a reflection of the greater likelihood of employment, higher level positions within a company, and adequate insurance coverage. They may seek health care through their doctor's office or a walk-in clinic. After age 64 years most patients will be retired and covered by Medicare and/or additional private insurance. This is reflected in the higher collection ratio of 73%. Their increased use of the ED is more likely a reflection of their increased frequency and severity of illness. The percentage Of patients by race showed a preponderance of whites (77.6%) versus blacks (20.3%). These numbers might differ somewhat if the Level I trauma centers in Miami, Jacksonville, Orlando, and Tampa were included° because ED populations are generally a reflection of the racial mix of the surrounding population. 14 Data were not available from these facilities, however.
Figure 5. Reiumbursment by acuity of patient Proportion of Charges 1,0-0.9 0.8-0.7-0.6-0.5-0.4-0.3-0.2 -0.1-0 . 0 - -
Emergent •
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Collected
Urgent
Semiurgent Acuity • Adjusted
Nonurgent Written Off
Retired persons are generally well insured, and this is reflected in the higher collection ratio of 72.1%. Employed adults exhibited a 56.2% collection ratio, which probably is indicative of the large n u m b e r of employed, uninsured patients in our patient population. Disabled persons exhibit a collection ratio of 47.8%, which is even lower than for adults who were not employed (48.8%). Many disabled patients qualify for Medicaid when they are initially disabled. But once these patients begin to receive Social Security Disability Income, they exceed the Medicaid guidelines for the state of Florida and so no longer receive benefits. When classified by first CPT code, 21% of the ED visits were extended or comprehensive. Most of these patients likely required admission to the hospital or at least prolonged observation in the ED itself. The remaining patients were less critical, although the visit may have been justified because we did not consider procedure codes along with level of service codes. So the severity of lacerations or fractures, which have both types of codes, may be underestimated. Forty percent of the visits were thought to be emergency or urgent based on discharge diagnosis, supporting the need for acute care in the ED. More patients present for evaluation of illnesses than injuries, although workers compensation patients will be heavily weighted toward the i n j u r y category. Other studies have indicated that injuries are higher in some age groups, so the predominance of i n j u r y versus illness varies from age group to age group. 4 Insurers seem more willing to reimburse for those patients with serious illnesses or injuries because the collection ratios for extended and comprehensive visits were higher than those for intermediate and limited visits. These collection ratios show a similar relationship with severity of illness, because they are higher for emergency and urgent conditions than semiurgent and nonurgent ones. However, it should be noted that adjustments were substantial for such government-funded programs as Medicare, Medicaid, and workers compensation. These ratios were not affected by severity of illness, injury, or level of care provided. Physicians who evaluate large numbers of Medicaid patients may have substantial uncollectible amounts because of these adjustments. At present, collections are reasonable for Medicare patients, but as pressures increase to contain spending, the level of adjustments could accelerate and materially affect this ratio. Actual write-offs because of bad debt were highest among the patients who were identified as self-responsible and were concentrated in the 19-to-39-year age group. Although patients who were not employed were more likely to fall in this group, the percentage (42.9%) was not as different from employed (36.0%) as might be expected. As previously mentioned, many of these patients may be employed by businesses that do not provide health care insurance. In addition, many men in this age group who are unemployed may not be
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eligible for Medicaid in the same p r o p o r t i o n as unemployed women. Bad debt tended to be higher in the less urgent patients, probably because these patients use the ED as their family physician. This is further supported by the higher b a d debt ratios for brief, limited, and intermediate CPT treatment codes. Also, seriously ill or injured patients may subsequently qualify-for some medical coverage (county funded, Medicaid, Medicare). Two thirds of self-responsible patients never made any payments after 12 months. This result might be anticipated. But surprisingly, almost one q u a r t e r of patients with commercial insurance also paid nothing for services provided. Most of these patients are either employed, dependents of someone who is employed, or victims of automobile accidents. [nsurance coverage may be inadequate to cover some illnesses or injuries, so the patient chooses to pay nothing either. Each emergency physician in this study provided approximately $103,700 of uncompensated and discounted care to patients presenting to their EDs in 1988. This compares favorably with the $20,900 provided by group practice physicians in Wisconsin in 1988.12 The discrepancy is likely due to the higher number of Medicaid and uninsured patients seen in emergency settings. Limitations of this study are largely related to the lack of data from Florida's four Level I t r a u m a centers. However, this omission p r o b a b l y tends to cause the p r o p o r t i o n of uninsured patients and the amount of uncompensated care to be underestimated. The results presented herein are, therefore, conservative.
REFERENCES 1. Inglehart JK: Medical care of the poor-A growing problem. IVEnglJMed 1985;313:59-63. 2. Melnick GA, Mann J, 6elan I: Uncompensated emergency care in hospital markets in Los Angeles County. Am J Pubfic Health 1989;79:514-516. 3. Lewin LS, Eckles TJ, Miller LB: The provision of uncompensated care by not-for-profit hospitals. N Engl J Med1988;318:1212-1215. 4.6reene J: Trauma in the emergency department. Modem Health Care 1988;18:28-33. 5. Podolsky ML: Patients, providers, and payers. Private Practice 1988;20:23-28. 6. O'6rady KF, Manning W6, Newhouse J, et al: The impact of cost sharing on emergency department use. N Engl J Mef11985;313:484-490. 7. Weissman JS, Stern R, Fielding SL, et al: Delayed access to health care: Risk factors, reasons, and consequences. Ann Intern Med1991;114:325-331. 8. Epstein A, Stern R, Tognetti J, et al: The association of patients' socioeconomic characteristics with the length of stay and hospital charges within diagnosis-related groups. N Engl J Med 1988;318:1579-1585. 9. Schiff RL, Ansell DA, Schlosser JE, et ah Transfers to a public hospital: A prospective study of 467 patients. N Engl J Med 1986;314:552-557. 10. Rice MF: Equity issues in inner city hospital care: Patient dumping, emergency care, and public policy. J Health Hum Resaurc Adm 1988;10:289-296. 11.0hsfeldt RL: Uncompensated medical services provided by physicians and hospitals. Med Care 1988;23:1338-1344. 12. Durham NO, Kindig DA, Lastiri-Quiros S, et al: Uncompensated and discounted Medicaid care provided by physician group practices in Wisconsin. JAMA 1991;265:2982-2986. 13. Koenig J: No more running from indigent care. Florida Trend1989;32:21-23. 14. Torrens PR, Yedvab DG: Variations among emergency room populations: A comparison of four hospitals in New York City. Med Care 1970;8:60-75. The authors thank Gettlieb's Financial Services, Jacksonville, Florida, for their assistance with data collection. They also thank Stephen J Dresnick, MD, FACEP, for helpful comments.
CONCLUSION
Significant policy implications are a p p a r e n t from this study regarding proposed changes in reimbursement and improved access to health care. The emergency physicians in this study participated in Medicaid and accepted assignment for Medicare patients for 100% of claims submitted. A comparison from Health Care Financing Administration data for 1987 supplied to the American College of Emergency Physicians indicates that 91.2% of Medicare services were provided on assignment (personal communication, J u d y Young, ACEP). The results of this study indicate that emergency physicians contribute significantly toward the care of all patients who are critically ill, severely injured, or simply have no other place to go for care. Serious consideration must be given to the magnitude of "free" care currently given to self-responsible patients by proponents of universal health care. F u r t h e r cuts in the level of reimbursement from government agencies could begin to compromise both the quality and availability of care to the very groups the programs are designed to protect.
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Address for reprints: Toni A Mitchell, MD, MBA, FACEP The Emergency Associates for Medicine 4 Columbia Drive, Suite 810 Tampa, Florida 33606
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