title: "Patients who can't get an appointment go to the ER": access to specialty care for publicly insured children.
abstract: OBJECTIVE
  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).
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors: Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Karin.Rhodes@uphs.upenn.edu
authors: Karin V
authors: KV
authors: Rhodes
authors: Joanna
authors: J
authors: Bisgaier
authors: Charlotte C
authors: CC
authors: Lawson
authors: David
authors: D
authors: Soglin
authors: Steven
authors: S
authors: Krug
authors: Martha
authors: M
authors: Van Haitsma
mesh_terms: D002648:Child; D002662:Child Health Services / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D008484:Medicaid / Q000706:statistics & numerical data*; D008511:Medicine / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D014481:United States