Medicaid HMO enrollees in the emergency room: Use of non-emergency care

摘要

This study examined economic, sociological, and psychological factors associated with the use of hospital emergency departments (EDs) by Medicaid enrollees in an HMO. Medicaid programs throughout the nation are moving rapidly to enroll beneficiaries into managed care plans, partly due to the belief that managed care can lower costs by reducing inappropriate ED use. Yet research on Medicaid managed care does not explain why variations in ED use; nor does it distinguish between emergency and non-emergency ED use or include attitudes and beliefs about health care as possible explanatory variables.;The present study addressed these gaps in the literature by using a multivariable logistic regression model of factors associated with the likelihood that a non-emergency ambulatory visit was to an ED rather than a doctor's office. Data came from a consumer satisfaction survey completed by a random sample of 640 Medicaid enrollees in a Colorado HMO and utilization information provided by the HMO.;Conditional on other variables in the model, the study found that non-emergency visits are less likely to be to the ED when made by women or people who are older, speak English as a primary language, are satisfied with the HMO and their doctor, do not feel vulnerable to illness, are willing to seek care from their physicians, report they know how and when to seek care, have more primary care visits, and are enrolled longer in the HMO. In contrast, non-emergency visits on weekends and those by people who live farther from their physicians, are disabled, or have more inpatient admissions are more likely to be to the ED. The results persisted across alternative definitions of emergency visits using ICD-9 codes. Perceptions of what constitutes an emergency are likely to vary among patients, ED professionals, and third party payers such as health plans.;Findings indicate that familiarity with the medical care system and experience with the HMO, geographic distance from providers, cultural and language differences, and attitudes and beliefs such as satisfaction with the physician and the HMO, knowledge of how and when to seek care from the primary care physician, and perceived vulnerability to illness can help explain why some people enrolled in an HMO continue to use the ED for non-emergency care and suggested policy options to address these psychological, economic, and sociological barriers to access to primary care providers.