Emergency department utilization patterns for a sample with employer-based health insurance

Currently, 63.4% of the U.S. population has some form of health insurance as a benefit of employment. As the cost of healthcare continues to increase, many employers are reducing insurance benefits and/or increasing the employee portion of cost sharing. Little is known about the differences in utilization among enrollees of the different types of employer based health insurance plans. This study classified and then sorted the five basic types of commercial health insurance plans (commercial, preferred provide organization, point of service with no capitation, point of service with capitation and health maintenance organization) by degrees of restrictiveness, utilizing the following parameters for restrictiveness: required assignment of a primary care provider, financial incentive to use a provider list, gatekeeping, capitation or services, penalties for going out of network and visit copayment requirements. It was hypothesized that as degree of restrictiveness increased, emergency department utilization would also increase. The hypothesis was tested through secondary analysis of the 1998 MarketScanR database.; The study found that for this sample (N = 860,291) enrollees in the health maintenance plan (the most restrictive type), were 4 times more likely than enrollees in the less restrictive plan types to have an emergency department visit, and where a doctors office visit copayment is high, emergency department utilization is more likely, and where the doctor office visit copayment is low, emergency department visit utilization is less likely. The reasons for emergency department visits were similar for all plan types.; It is important to monitor utilization of services for this segment of the population. As employers change the type of health benefits for their employees, utilization patterns are likely to change.