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Editor's Note
June 2016

Triage, Copayments, and Emergency Department Visits

Author Affiliations

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Intern Med. 2016;176(6):854-855. doi:10.1001/jamainternmed.2016.0882

Use of the emergency department (ED) for nonurgent care is frequent and costly. These costs are of particular concern to state Medicaid programs, whose beneficiaries generally experience diminished access to primary care and may be more likely to rely on the ED for nonurgent care. The Deficit Reduction Act of 2005 gave state Medicaid programs the authority to impose cost-sharing strategies on certain services, including copayments for nonurgent visits to the ED. While copayments have been shown to broadly reduce use of the ED,1 recent evidence suggests that allowing states to impose copayments for nonurgent visits did not impact ED use among Medicaid beneficiaries.2 However, these copayments are still likely to have an effect on the financial lives of Medicaid beneficiaries and other individuals whose insurance plans have adopted similar policies.

In this issue of JAMA Internal Medicine, Hsia and colleagues3 examined the validity of triage assessment of visit urgency in the ED. Their findings raise concerns. While 7.5% of ED visits were deemed nonurgent on triage, 4.4% of the nonurgent visits resulted in hospital admission, one-sixth of which were admissions to critical care units. Nearly half of the nonurgent visits involved some amount of diagnostic testing and one-third involved medical procedures. Some of this care may have been safely provided in primary care settings, but it is unknown if these individuals had timely access to primary care services. Nevertheless, the findings by Hsia and colleagues3 suggest that there is some uncertainty during ED triage assessment of visit urgency and policies that are based on this assessment must take this uncertainty into account or risk unfairly, and inappropriately, imposing cost-sharing penalties.

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Article Information

Conflict of Interest Disclosures: None reported.

Selby  JV, Fireman  BH, Swain  BE.  Effect of a copayment on use of the emergency department in a health maintenance organization.  N Engl J Med. 1996;334(10):635-641.PubMedGoogle ScholarCrossref
Siddiqui  M, Roberts  ET, Pollack  CE.  The effect of emergency department copayments for Medicaid beneficiaries following the Deficit Reduction Act of 2005.  JAMA Intern Med. 2015;175(3):393-398.PubMedGoogle ScholarCrossref
Hsia  RY, Friedman  AB, Niedzwiecki  M.  Urgent care needs among nonurgent visits to the emergency department [published online April 18, 2016].  JAMA Intern Med. doi:10.1001/jamainternmed.2016.0878. Google Scholar