Insurance Copayments and Delays in Seeking Emergency Care

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Abstract
Dr. Magid and colleagues (June 12 issue)1 provide interesting data on the correlates of delays in seeking treatment among patients with acute myocardial infarction. Because they studied only one health maintenance organization (HMO), the authors are appropriately circumspect about generalizing the observed nonassociation between cost sharing and treatment delay to other HMOs and to low-income populations at risk. However, the report and Dr. Selby's editorial2 neglect to discuss an important limitation to internal validity that should have tempered their conclusion that “in this HMO, the requirement of modest, fixed copayments for emergency services did not lead to delays in seeking treatment for myocardial infarction.”1 The cross-sectional, “post-only-with-comparison-group” design is one of the weaker quasi-experimental designs for measuring the impact of a policy.3 The absence of base-line observations makes it impossible to know whether for the population who made the copayment the delay was longer, shorter, or the same before the policy was implemented.