Access to emergency departments: a survey of HMO policies

An unresolved question related to the practice of health maintenance organizations' (HMOs) controlling access to medical care is whether such screening of patients seeking emergency department treatment impairs efficient patient care or endangers patients. A preliminary study was undertaken to determine whether so-called gatekeeping of access to EDs was common practice. Medical directors of HMOs in 39 states and the District of Columbia were surveyed by a mail questionnaire to assess policies regarding ED access. There were 98 (80.3%) respondents to 122 questionnaires, representing 26% of all federally qualified HMOs in the United States. Of the 98 respondents, 90 (92%) used the distinctions "life-threatening" and "nonlife-threatening" in defining their ED access policies. In life-threatening situations, members were permitted to go to any hospital without calling the gatekeeper first. In nonlife-threatening situations 78 of 98 (80%) required that permission be obtained prior to an ED visit. Most required a telephone call; nonphysicians could act as gatekeepers in 46 of 78 (59%). Thirty-nine percent of the 98 respondents limited their members to using the EDs of certain hospitals only. Ninety-four of 98 (96%) reviewed all ED visits prior to making any payment. We discuss here the implications of these gatekeeping policies.