Study Finds HMO Emergency Instructions Confusing

06/30/99    Portland, Ore.

Researcher says vague language could affect patient care

A new study of membership instructions from health maintenance organizations (HMOs) found that some instructions are complex and confusing, possibly causing members to call their health plans first before going to an emergency department when ill or injured.

The study, by Keith William Neely, MPA, associate professor of emergency medicine and Ph.D. candidate at Oregon Health Sciences University, is featured in the July issue of Annals of Emergency Medicine.

"This study argues for a prudent layperson definition of `emergency,' basing health plan coverage decisions on a patient's presenting symptoms, not his or her final diagnosis," said Neely. "Such a standard would place the ability to decide when an emergency condition exists with the patient, not the payer."

Fifteen of the 28 HMOs contacted for the survey (54 percent) provided membership materials. Nine required members themselves to make a distinction between "emergency" and "urgent" situations. Four provided no option for calling 911 or going directly to an emergency department. Three discouraged emergency department use by suggesting "overuse of emergency rooms makes health care more expensive for everyone" and "a large number of patients with minor problems can make it hard for a hospital to manage true emergencies - when every second counts."

HMO membership has risen rapidly in recent years. About 23 percent of the Medicaid population is enrolled in HMOs, while nearly 90 percent of all physicians have at least one managed care contract.