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Managing Indigent Care: A Case Study of a Safety-Net Emergency Department


  • Daniel Dohan

This research was supported by the Robert Wood Johnson Foundation Scholars in Health Policy Research Program and a National Institute of Alcohol Abuse and Alcoholism Post-Doctoral Fellowship in Alcohol Studies at the Alcohol Research Group/Prevention Research Center and School of Public Health, University of California, Berkeley. Preliminary findings were presented at the Annual Meeting of the Robert Wood Johnson Foundation Scholars in Health Policy Research Program, Aspen, CO, June, 1999. Kim Matsubara transcribed most of the interviews. Helpful feedback was received from Charles Branas, Christopher Gaut, Ruth Malone, Howard Pinderhughes, Mart ín S ánchez-Jankowski, and participants in the Writing Seminar at the Institute for Health Policy Studies, University of California, San Francisco. Laura Schmidt and a Health Services Research reviewer provided extensive comments on earlier drafts of this article. This research would not have been possible without the cooperation and contributions of staff and clients at County Hospital.

Address correspondence to Daniel Dohan, Ph.D., Institute for Health Policy Studies, Box 0936, University of California San Francisco, 3333 California St., Suite 265, San Francisco, CA 94118. This article, submitted to Health Services Research on November 29, 1999, was revised and accepted for publication on November 6, 2000.


Objective. To examine how one safety-net emergency department (ED) managed problems associated with the provision of indigent care in everyday life.

Data Sources/Study Setting. Interview and observational data collected in County Hospital ED, a public teaching hospital in a California city, during 6 months of 1999.

Study Design. The study used ethnographic methods to document and understand day-to-day routines and practices for providing indigent care in a safety-net facility.

Data Collection/Extraction Methods. One- to 2-hour semistructured interviews with a snowball sample of eight ED physicians were tape recorded, and fieldnotes were recorded in situ during 10–30 hours of participant observation per week in all areas of the ED. Data were coded to highlight themes of interest and to identify recurrent patterns of behavior.

Principal Findings. In everyday life, providers at County ED relied on graduate medical education (GME) to manage two everyday problems, social use and tenuous financing, associated with the provision of indigent care. GME helped manage problematic social visits to the ED by defining them as interesting cases. GME helped with tenuous finances by creating a work culture that encouraged the provision of uncompensated work.

Conclusions. Safety-net facilities often face problems similar to those in County ED. Future research should assess the extent to which the everyday management of these problems in County ED resembles that in other safety-net facilities.