Objectives: Since World War II, the urban hospital emergency room has been a major source of medical care for inner-city poor families, many of whom receive Medicaid. Given the expensive and episodic nature of emergency room care, there has been renewed interest in enrolling Medicaid recipients into managed care plans to increase access to care and to reduce medical costs. Thus, the primary care physician, in many managed care plans, is expected to give prior approval for emergency room care in nonurgent situations. The goals of managed care may create tension between its requirements and historical patterns of inner-city families seeking care in an emergency room. In 1964, Alpert developed a typology that categorized inner-city families' patterns of seeking medical care in a pediatric emergency department (PED) by describing the relation between regular source of medical care and reliance on this source before the PED visit. In 1976, using the same typology, Alpert and Scherzer updated care-seeking patterns in Boston after the introduction of neighborhood health centers (NHCs) and Medicaid. In 1993, the typology is a method that can be used to assess the impact of managed care on PED utilization by inner-city families. This article compares the 1993 pattern of seeking PED care with that measured in 1964 and 1976.
Methods: In 1964, 1976, and 1993 families were interviewed as they sought care in a PED. Families were asked if they had a regular source of care, defined as the place where families take their child most often for either well or sick visits. A judgment was made as to whether or not the PED visit was coordinated with their regular source of care. Coordinated care was defined as having a regular source of care and attempting to contact the source before the PED visit. Uncoordinated care occurred when the family had a regular source and did not attempt contact, or had no regular source.
Results: In 1964, 63% of families reported a regular source of care compared with 89% in 1976 and 95% in 1993. The hospital was reported as the regular source of care by 57% of the respondents in 1964, by 31% in 1976, and 43% in 1993. Community-based sources (physicians and NHCs) were identified as a regular source of care by 43% in 1964, 69% in 1976, and 57% in 1993. In 1964, 55% of the families engaged in an uncoordinated pattern of seeking care compared with 64% in 1976 and 72% in 1993.
Conclusions: Efforts to provide access to care through Medicaid, NHCs, and hospital-based primary care resulted in a greater percentage of families reporting a regular source of care; however, a majority of families continue to exhibit an uncoordinated pattern of seeking care. More families in 1993 did not contact their regular source before seeking care in the PED when compared with 1964 and 1976. For managed care plans to increase access and reduce costs, a shift in PED utilization patterns remains necessary. The primary care system must have the capacity to accommodate these changes and considerable patient education must occur if urgent care is to be provided outside the PED.