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KCE reports vol. 19B Urgences 9
delayed or avoided emergency care compared with only 6% of subjects who thought
their co-payment was less than $20 (Odd Ratio 3.6, 95 CI 1.6-7.8). No difference was
found in the relationship between perceived co-payments and behaviour change by
income or by the number of ED visits in the past 12 months, i.e., there were no
statistically significant effects. Persons with low levels of self-reported health status were
significantly more likely to delay care (16%) than subjects with high self-reported levels
of health care (5%). The authors also found that many patients underestimated their
actual ED co-payment, and that they were much more knowledgeable of their copayment
for physician office visits and prescription drugs. One of the limitations of this
study is that it only addresses the question whether patients altered their decisions to
seek ED care because of the financial incentive and did not address perceived need for
care or the availability of alternative sources of care. ItÊs therefore also impossible to
tell whether the behavioural changes represented reductions in inappropriate use or in
appropriate use.
Shapiro et al. 11 studied the effect of cost-sharing on seeking care for serious and minor
symptoms by analyzing data for 3539 persons aged 17 to 61 from the Rand Health
Insurance Experiment. In the latter experiment, participants were randomly assigned to
a free-care group or to insurance plans requiring them to pay part of the costs (costsharing
group). The study does not address specifically patients presenting to the
emergency department. The authors found that the cost-sharing group was nearly one
third less likely than the free-care group to see a physician when they had minor
symptoms (6.3% compared with 9.0%; p