A number of national initiatives have focused attention on persistent racial and ethnic disparities in health and health care. The rising tide of improvements in health has not raised all boats; in some cases, the health gap between whites and minorities has widened. Although many social and economic forces contribute to this gap, inequitable access to health care also plays a part. This Issue Brief examines a common strategy that managed care organizations use to reduce emergency department visits—gatekeeping—and describes a study of the differential impact it may have on African Americans

Lowe, Robert A

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Kosmopolis

Does Managed Care Gatekeeping Affect African Americans’ Access to Emergency Care?

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University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics4-20-2001Does Managed Care Gatekeeping Affect AfricanAmericans’ Access to Emergency Care?Robert A. LoweFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/20For more information, please contact repository@pobox.upenn.edu.Lowe, Robert A.. Does Managed Care Gatekeeping Affect African Americans’ Access to Emergency Care?. LDI Issue Briefs. 2001; 6(7). http://ldi.upenn.edu/policy/issue-briefs/2001/04/20/does-managed-care-gatekeeping-affect-african-americans-access-to-emergency-careDoes Managed Care Gatekeeping Affect African Americans’ Access toEmergency Care?AbstractA number of national initiatives have focused attention on persistent racial and ethnic disparities in health andhealth care. The rising tide of improvements in health has not raised all boats; in some cases, the health gapbetween whites and minorities has widened. Although many social and economic forces contribute to thisgap, inequitable access to health care also plays a part. This Issue Brief examines a common strategy thatmanaged care organizations use to reduce emergency department visits—gatekeeping—and describes a studyof the differential impact it may have on African Americans.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/20Leonard Davis Institute of Health EconomicsLDI Issue BriefVolume 6, Number 7April 2001Robert A. Lowe, MD, MPHLDI Senior Fellow,Assistant Professor of EmergencyMedicine and EpidemiologyUniversity of PennsylvaniaManaged careorganizations can requirepreauthorization ofemergency department careDoes Managed Care Gatekeeping AffectAfrican Americans’ Access to Emergency Care?Editor’s note: A number of national initiatives have focused attention on persistentracial and ethnic disparities in health and health care. The rising tide ofimprovements in health has not raised all boats; in some cases, the health gapbetween whites and minorities has widened. Although many social and economicforces contribute to this gap, inequitable access to health care also plays a part.This Issue Brief examines a common strategy that managed care organizations useto reduce emergency department visits—gatekeeping—and describes a study of thedifferential impact it may have on African Americans.To reduce costs and improve care, managed care organizations have used variousstrategies to discourage visits to the emergency department (ED) for nonurgent care.One of the most common approaches is “gatekeeping”—requiring preauthorizationfor ED care as a condition to paying for that care.• Typically, the gatekeeper is a primary care provider or managed care employeewho must approve the ED visit for payment.  The patient or ED staff usuallycalls the gatekeeper, describes the symptoms, and requests approval.  If the visitis denied, the patient can choose to be seen anyway, but may be liable for thecharges incurred.• The clinical and economic rationale for gatekeeping has been questioned.  Doesit reduce costs? Does it erect barriers to needed care?  Can a gatekeeper reliablyassess the urgency of symptoms over the phone?• In response to concerns about gatekeeping, Congress passed legislation in 1997that mandated the “prudent-layperson standard” for Medicare and Medicaidenrollees.  According to this standard, health plans must cover emergency servicesfor these patients if the patient shows symptoms that a prudent layperson,possessing an average knowledge of health and medicine, could reasonably expectto result in serious health impairment.  This standard has since been extended toall enrollees in federal health benefits plans.• More than 30 states have passed legislation requiring a prudent laypersonstandard for emergency care in all health plans. However, employees of largecompanies that “self-insure”—roughly 40% of all employees with commercialhealth insurance—are exempt from state regulation, and may still be subject togatekeeping requirements.Pilot study suggests thatAfrican Americans weremore likely to be deniedauthorization foremergency careLarger study investigatesrole of race, other factorsin gatekeeping decisionsAfrican Americans were52% more likely thanwhites to be deniedauthorizationThe impetus for examining the link between race and ED gatekeeping came from a1994 pilot study by Lowe and colleagues that identified how gatekeeping decisionswere made. The study compared managed care patients in one Philadelphia ED whohad been denied authorization (“cases”), with similar patients whose ED visits wereapproved (“controls”).• Patients were enrolled in one of nine health plans. Each case was matched tocontrols enrolled in the same health plan.  At the time, all plans required pre-authorization for ED care.• Of the 195 patients with approved visits, 54 (28%) were white. Of the 49patients whose visits were not approved, only 4 (8%) were white.• This finding could have resulted if African American patients tended to go to EDsfor less severe conditions.  However, after statistically adjusting for the severity oftheir symptoms, African Americans were still 3.4 times more likely to be deniedauthorization than were whites.• This disparity, by race, was unexpected and troubling.  The authors launched alarger study to confirm these findings and identify other explanations.Lowe and colleagues evaluated the records of more than 15,000 visits to aPhiladelphia emergency department from January 1995 to June 1996.  They studiedthe records of white and African American patients enrolled in health plans thatpracticed gatekeeping.  In addition to race, the study examined other factors thatmight influence gatekeeping decisions, such as the age and gender of the patient,severity of symptoms, type of health plan (commercial, Medicaid or mixed), and dayand time of ED visit.• Of the ED visits included in the study, most (73%) were by African Americans,and 67% were by Medicaid beneficiaries. Only 34% of visits occurred duringusual office hours (Monday-Friday, 8 a.m. to 5 p.m.)• All patients were initially evaluated by a nurse in the emergency department, andgiven a “triage score” that rated the severity of symptoms on a four-point scale.African Americans tended to have lower triage scores, indicating less severeconditions.• 682 patients (4.4%) were denied authorization by their managed care gatekeepers.Of these denied visits, 22% were rated as more severe than the “minor” triagecategory by the ED nurse.  This suggests a discrepancy between triage nurses andgatekeeper assessments of the severity of symptoms.Through statistical analysis, the authors identified factors that predict gatekeeperdenials.  African American ethnicity, type of health plan, severity of symptoms, andday and time of ED visit were all significant predictors of ED denials.• As expected, visits in “minor” triage category were 56 times more likely to bedenied than visits categorized as “urgent”.POLICY IMPLICATIONSFindings indicate thatgatekeeping is a barrier toemergency care for AfricanAmericans, although thereasons are unclear• Patients were more likely to be denied on weekdays, especially during usual officehours, than on weekends.• After accounting for other significant factors, African Americans remained 52%more likely than whites to be denied authorization for care.Many of the factors that predict ED denials have plausible explanations. Ifgatekeeping works, it  should deny authorization to patients with nonurgentproblems. And gatekeepers might be more inclined to deny authorization for care inthe ED on weekdays, when primary care providers have office hours.  But thereasons are less clear for why, all other things being equal, Medicaid patients andAfrican Americans were more likely to be denied authorization for ED care.• The study findings do not suggest that gatekeepers, health plans, or ED staff areracist; in fact, most gatekeepers were part of large physician groups and probablydid not know the race of the patient.  It is possible that ED staff were moreaggressive in appealing initial gatekeeping decisions for white patients than forAfrican Americans, but no evidence, even anecdotal, supports this hypothesis.• It is possible that African Americans and whites tended to go to different primarycare providers, and that providers treating African Americans were more likely todeny authorization.• Another possible explanation is that African Americans and Medicaid enrolleeswere less effective advocates for themselves in the gatekeeping process, which relieson somewhat subjective assessments of need for ED care.For ED gatekeeping to be ethical, the process should not be influenced bynonmedical factors such as race. The study raises important questions about theequitable application of gatekeeping across racial groups and, therefore, theappropriateness of using gatekeeping to reduce use of the ED.  To the extent thatmanaged care gatekeeping of ED visits persists, more extensive study of the reasonsfor these inequities is warranted.• This study provides support for the changes in managed care policies, regulationsand legislation that occurred in Philadelphia after the data were collected.  At leastone Medicaid health plan dropped the requirement for preauthorization of EDvisits even before the federal regulations required the change.• Partially in response to the findings of this study, a coalition of researchers, healthplans, state and local regulators, and patient advocates has formed in Philadelphiato explore strategies to reduce the costs of ED care without incurring the risks ofED gatekeeping. One promising approach is to improve enrollees’ access toprimary care services, thereby reducing reliance on the ED for nonurgent care.• The prudent layperson standard for emergency services has been included inpatients’ rights bills now before Congress. These bills would extend the standardto all commercially insured people, and is one of the least controversial aspects ofthis legislation.  However, passage remains blocked by a lack of consensus onother aspects of the bills, such as health plan liability.This Issue Brief is based on the following article:  R.A. Lowe, S. Chhaya, K. Nasci, L.J. Gavin, K. Shaw, M.L. Zwanger,J.A. Zeccardi, W.C. Dalsey, S.B. Abbuhl, H. Feldman, J.A. Berlin. Effect of ethnicity on denial of authorization for emergencydepartment care by managed care gatekeepers.  Academic Emergency Medicine, March 2001, vol. 8, pp. 259-266.Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA19104-6218, 215-898-5611.Janet Weiner, MPH, Associate Director for Health Policy, EditorDavid A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic,and social and ethical issues that influence how health care is organized, financed, managed, and delivered in the United Statesand internationally. The LDI is a cooperative venture among Penn schools including Dental Medicine, Medicine, Nursing andWharton. For additional information on this or other Issue Briefs, contact Janet Weiner (e-mail: weinerja@mail.med.upenn.edu;215-573-9374).Visit us on the web at www.upenn.edu/ldi© 2001 Leonard Davis InstituteNonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue Brief Published by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTED

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Does Managed Care Gatekeeping Affect African Americans’ Access to Emergency Care?

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