Do HMOs drive blacks to the emergency room?

Originally published in MedPage Today

by John Gever, MedPage Today Senior Editor

Many African-Americans in California enrolled in health maintenance organizations (HMOs) appear to prefer getting medical treatment in emergency rooms, researchers said.

One-quarter of African-Americans enrolled in Kaiser Permanente or other commercial HMOs in California, who would therefore have a range of treatment options, sought treatment in emergency rooms in 2007, compared with about 18% of white, 17% of Latino, and 13% of Asian/Pacific Islander members of HMOs, reported Dylan Roby, PhD, and other researchers in the UCLA Center for Health Policy Research in Los Angeles.

Those findings emerged from a study commissioned by the California Office of the Patient Advocate which was published online as a policy brief.

The researchers analyzed 2007 data from the California Health Interview Survey, in which some 50,000 state residents provided information on health status and service usage in the previous year.

They found that emergency room treatment was more common for African-Americans in the Kaiser system even after controlling for overall health status, income, age, and gender, and even when they reported having a usual source of care (OR 1.5, P<0.05 versus whites).

“This disparity suggests other barriers still exist for HMO-enrolled African Americans in California in terms of avoiding ER visits,” Roby and colleagues wrote.

That finding might reflect the unique design of Kaiser, which has an integrated model that places a variety of services, including emergency departments, pharmacies, and urgent care clinics on a single campus.

“This type of convenience and increased access to ER services could potentially impact patterns of use among Kaiser enrollees,” Roby and colleagues said.

“If it takes days or weeks to get an appointment with your doctor and just hours to be seen in the ER, people might make the easier choice, especially if it is convenient and affordable,” Roby said in a press statement. “On the other hand, if someone knows their local ER is overcrowded and expensive, they may be more likely to wait and see their own doctor.”

They also suggested that many members of Kaiser and other HMOs could lack a “medical home” within those systems, which may also make ER treatment more appealing than it might otherwise be.

But these factors do not explain why African-Americans would be more likely than other racial and ethnic groups to seek treatment in emergency departments.

African-Americans in California are more likely to belong to HMOs than other groups, the researchers noted. Two-thirds of insured blacks in the state were HMO members, with 25% enrolled in the Kaiser system.

Just over half of whites were in HMOs, with 15% belonging to Kaiser.

“Several studies have suggested that even commercially insured individuals with a usual source of care are being referred to use the ER by their physicians due to complicated cases, limited availability of alternative or specialty providers, convenience, greater availability of diagnostic tests, and liability issues,” the researchers said.

They also pointed out that the racial-ethnic differences in ER usage “could be related to other physician practices and patient behaviors that are not easily measured.”

Roby recommended an education campaign for both patient and provider that would address appropriate use of the ER and primary care services, as well as the importance of medication adherence and getting prescribed medications and refills.

“African-American HMO members need to be empowered to find a doctor they are comfortable with, while health plans need to make a greater effort to connect patients with that doctor,” he said.

Another finding of the study was that African-Americans in HMOs tended to delay getting drug prescriptions filled.

More than 16% of black HMO members reported delay in filling prescriptions, compared with 11% of white members and less than 9% of Latinos and Asian/Pacific Islanders.

After controlling for sociodemographic and health variables, the difference was not significant overall or for Kaiser members. But the odds ratio for other insured African-Americans versus whites was 1.7 (P<0.05), the researchers found.

African-American members of the non-Kaiser plans may be especially daunted by higher copayments, limited drug benefits, or lack of access to in-network pharmacies, Roby and colleagues speculated.

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