Health Plans

Primary care physicians (PCPs) can influence HMO members' emergency department use depending on the financial risk PCPs face for patients' emergency care, according to a study published in the American Journal of Managed Care.

Researchers in the study examined data on 217,298 members enrolled in Blue Care Network of Michigan HMO plans. Network PCPs had varying levels of financial risk for emergency care. The authors found that among members whose PCPs faced moderate financial risk, ED utilization was 15.9% lower than among members whose PCPs faced a low risk. For patients of PCPs with high financial risk for emergency care, ED utilization was 24.4% lower than among PCPs with low financial risk.

According to the study, ED usage also is influenced by:

Access to emergency care;
Copayments;
Demographics; and
Number of Blue Care members assigned to a PCP.

The authors concluded that PCPs can influence HMO members' ED use, particularly when members are enrolled in capitated health plans that offer negative incentives for PCPs to provide adequate access to primary care and to help members avoid unnecessary ED visits. In addition, researchers found that a higher level of cost sharing by members and PCPs lowers ED utilization.

The study recommends that HMOs with capitated health plans offset the negative incentive, for example, by creating secondary risk pools for services including emergency care. PCPs also should have an adequate number of patients under a specific contractual agreement to create financial incentives for doctors to promote more limited use of emergency care (Goodman, American Journal of Managed Care, June 2006). This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.