By Merritt McKinney

NEW YORK, Mar 26 (Reuters Health) - African-American patients seeking emergency department care are about 50% more likely than white patients to be denied authorization by their managed care organization, according to a report.

The reason is unclear, but the study's lead author told Reuters Health that the findings call into question "gatekeeping"--the practice health plans use to reduce unnecessary trips to hospital emergency departments by requiring patients to seek preauthorization for emergency care.

Experts have questioned whether gatekeeping constitutes good healthcare and actually reduces costs. And a previous pilot study found that African Americans were much more likely than whites to have their requests for emergency care denied.

To see whether blacks really are denied authorization for emergency department care more often than whites, a team of researchers led by Dr. Robert A. Lowe of the University of Pennsylvania in Philadelphia evaluated the records of more than 15,000 visits to a Philadelphia emergency department. Their findings are published in the March issue of Academic Emergency Medicine.

All emergency department patients in the study were first seen by a nurse who evaluated the severity of their symptoms. Patients in dire need of medical care were treated immediately and no authorization was sought. In less serious cases, either the patient or a staff member called the patient's primary care physician or an official at the managed care plan to seek approval for the emergency care.

African Americans tended to have less severe symptoms than whites, so the researchers took this into account, as well as several other factors that could have influenced the authorization process, including the day and time of the visit to the emergency department, type of managed care plan and each patient's age and gender.

Still, blacks were 52% more likely than whites to be denied authorization for care, Lowe's team found.

Requests were also more likely to be denied on weekdays, especially during normal business hours. The investigators also found that patients in Medicaid managed care plans and plans that included both Medicaid and non-Medicaid patients were more likely to have their claims denied than patients enrolled in commercial managed care plans.

The results "raise important questions about the equitable application of gatekeeping across racial groups and, therefore, the appropriateness of using gatekeeping to reduce emergency department utilization," Lowe's team concludes.

"What we found is not about racist doctors, nor is it about racist HMOs," Lowe told Reuters Health. "It is about barriers to accessing needed medical care."

In many cases, the person in charge of authorization, either a physician or an employee of a health plan, may not have known a patient's race, he noted. One possible explanation, according to Lowe, is that African Americans may tend to see physicians who, for whatever reason, are more likely to deny authorization for emergency care. He noted, however, that this study was not designed to test this idea.

"We need to dig deeper into the possible explanations for our findings, which add to the large body of literature suggesting that nonwhite patients receive different medical care than do whites," he concluded.

Since the study was conducted, at least one Medicaid managed care plan in the Philadelphia area has stopped using the gatekeeping practice. Instead, the plan pays for emergency care in cases when a "prudent layperson" would believe that emergency care was necessary. Prudent layperson legislation has been passed in a number of states, according to Lowe.

Even though the long-term effects of this standard remain to be seen, Lowe said that the move away from gatekeeping, which he dubbed the "stick" approach, towards a "carrot" approach of reducing emergency department visits by improving access to traditional healthcare, is an appealing development.

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