Insurance coverage and health care consumers' use of emergency departments: has managed care made a difference?

How successful has managed care been in controlling costs and consumers' inappropriate use of health care services? This study compares national data from 1992 and 1996 to determine the effect of managed care on appropriateness of ED utilization. ED utilization was described in two ways as defined in Gooding, Smith, and Peyrot (1996): (1) urgency of visit (urgent vs. non-urgent), and (2) appropriateness of visit taking into account the care provided upon visits (including treatment and diagnostic procedures) and disposition of visit (admit, transfer, and discharge against medical advice). Potentially appropriate visits were the non-urgent cases at which treatment procedures and/or non-routine diagnostic procedures were performed. All urgent visits were defined as appropriate. Study results reveal that consumers' ED misuse changed in complex ways over the period examined. Contrary to our assumptions based on earlier research, the pattern of change was not the same for the two different measures of misuse. Non-urgent use decreased, as hypothesized, but there was an increase in non-urgent use which we have defined as inappropriate (i.e., no treatment and no non-routine diagnostic tests). ED misuse did not decrease more for insured than uninsured consumers, nor more for managed care than fee-for-service consumers. These findings bring into question the efficacy of efforts to address rising health care costs through controlling consumer utilization of services via managed care, efforts mirrored by many fee-for-service indemnity plans. Future research is needed to determine why this consumer misuse of the ED appears to continue and how the recent increase in the marketing of ED services may exacerbate this problem.