Kristine Qureshi, RN, DNSc, Mailman School of Public Health, Columbia University, 722 West 168 Street, New York, NY 10032, 212 342 0555, kaq5@columbia.edu and Raymond R. Arons, DrPH, School of Public Health, Columbia University, 600 West 168th Street, New York, NY 10032.

Currently, 63.4% of the U.S. population has health insurance as a benefit of employment. As healthcare costs continue to increase, many employers are reducing health benefits and/or increasing the level of employee cost sharing. Little is known about differences in utilization among enrollees with various employer based health insurance plans. This study classified and then sorted five basic types of employer based health insurance plans (commercial, preferred provider organization, point of service with no capitation, point of service with capitation and health maintenance organization) by degrees of restrictiveness. Restrictiveness was defined by six elements: assignment of a primary care provider, financial incentive to use a provider list, gatekeeping for specialist access, capitation of services, penalties for going out of network and visit copayments. 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 (N=860,291 covered lives). The study found that enrollees in the most restrictive plan type (HMO), were 4 times more likely than enrollees in less restrictive plans to have an ED visit. In plans where a doctor’s office visit co-payment was high, ED utilization was more likely; where the doctor’s office visit co-payment was low ED visit utilization was less likely. Reasons for ED visits were similar for all plan types. As employees’ health benefits decrease, access to primary care services may be adversely affected. It is therefore essential to monitor access and utilization patterns for this population.

Learning Objectives: At the end of the session the learner will be able to

• explain the concpet of "health inssurance plan restrictiveness"
• discuss the impact of copayments on emergency department and primary care provider utilization

Keywords: Access to Care, Managed Care

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.