Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Ann Emerg Med. 2013 Apr;61(4):394-403. doi: 10.1016/j.annemergmed.2012.10.030. Epub 2013 Jan 8.
Emergency departments (EDs) frequently refer patients for needed outpatient specialty care, but little is known about the dynamics of these referrals when patients are publicly insured. Hence, we explored factors, including the role of ED referrals, associated with specialists' willingness to accept patients covered by Medicaid and the Children's Health Insurance Program (CHIP).
We conducted semistructured qualitative interviews with a purposive sample of 26 specialists and 14 primary care physicians in Cook County, Illinois, from April to September 2009, until theme saturation was reached. Transcripts and notes were entered into ATLAS.ti and analyzed using an iterative coding process to identify patterns of responses, ensure reliability, examine discrepancies, and achieve consensus through content analysis.
Themes that emerged indicate that primary care physicians face considerable barriers getting publicly insured patients into outpatient specialty care and use the ED to facilitate this process. Specialty physicians reported that decisions to refuse or limit the number of patients with Medicaid/CHIP are due to economic strain or direct pressure from their institutions. Factors associated with specialist acceptance of patients with Medicaid/CHIP included high acuity or complexity, personal request from or an informal economic relationship with the primary care physician, geography, and patient hardship. Referral through the ED was a common and expected mechanism for publicly insured patients to access specialty care.
These exploratory findings suggest that specialists are willing to see children with Medicaid/CHIP if they are referred from an ED. As health systems restructure, EDs have the potential to play a role in improving care coordination and access to outpatient specialty care.
急诊科（ED）经常将患者转介到需要的门诊专科护理，但对于公共保险患者的这些转介动态知之甚少。因此，我们探讨了与专家愿意接受医疗补助和儿童健康保险计划（CHIP）覆盖的患者相关的因素，包括 ED 转介的作用。
我们于 2009 年 4 月至 9 月在伊利诺伊州库克县进行了半结构化定性访谈，采用目的性抽样方法对 26 名专家和 14 名初级保健医生进行了访谈，直至达到主题饱和。将转录本和笔记输入 ATLAS.ti 并进行分析，使用迭代编码过程识别响应模式，确保可靠性，检查差异，并通过内容分析达成共识。
出现的主题表明，初级保健医生在让公共保险患者获得门诊专科护理方面面临相当大的障碍，并利用急诊室来促进这一过程。专科医生报告说，拒绝或限制 Medicaid/CHIP 患者数量的决定是由于经济压力或来自其机构的直接压力。与 Medicaid/CHIP 患者接受专家的因素包括高紧迫性或复杂性、与初级保健医生的个人请求或非正式经济关系、地理位置和患者困难。通过 ED 转介是公共保险患者获得专科护理的常见且预期的机制。
这些探索性发现表明，如果 ED 转介，专家愿意为 Medicaid/CHIP 的儿童提供治疗。随着医疗系统的重组，ED 有可能在改善护理协调和获得门诊专科护理方面发挥作用。
