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Unnecessary ER Visits Linked to Low Co-Pays
Relatively low co-pays also drive more visits to specialists

By Stephen Miller, CEBS  5/8/2012

Employees and their families in the U.S. are making more trips to the emergency room (ER), urgent care facilities and specialists’ offices as relatively low co-payment costs are narrowing the gap between those and other services—notably primary care physicians. The trends in employee co-pays are among the findings in the 2012 Medical Plan Trends Report by HighRoads, a provider of benchmarking data for HR plans, and Corporate Executive Board, a research and advisory services company.

The findings in the report are the result of the study conducted by Corporate Executive Board and HighRoads' The Lab benchmarking repository of health care benefit plan data, covering more than 34 million people and representing more than 12,000 plans throughout the U.S.

According to plan data, the average ER visit co-pay for Americans is just $76. The relatively low costs might be prompting employees to visit the hospital for symptoms that a primary care physician or other provider could treat more readily and more cost-effectively. For example, toothaches and sprains are among the most common conditions for which Americans visit hospital emergency rooms, according to the report.

While some ER visits are attributable to patients who lack insurance, the steady increase in visits appears predominantly to be tied to co-pay costs, the report found.

“The interesting data on co-pays show employees are basically acting as price-sensitive consumers and going for what they perceive as the best value and convenience for the price,” said Ania Krasniewska, senior director at Corporate Executive Board. “However, it also sounds a warning that some visits to ER and urgent care facilities should, in fact, be handled at the more cost-effective primary-care level. Not only does this affect cost to the employee in the end, but in large quantities this significantly affects the cost to the organization,” she observed.

Some Choices Based on Convenience, Not Price

The analysis found, on average, plans have a relatively minimal price differential between urgent care, in-network co-pays ($32) and primary care physician (PCP) co-pays ($17). As a result, employees might be choosing urgent care facilities for convenience because they tend to keep evening and weekend hours and are open on holidays.

Similarly, the price gap between specialists and PCPs is narrowing. From 2010 to 2012 the price differential dropped from 82 percent to 35 percent higher for specialist visits. The analysis shows that the closer the two costs get, the more likely employees are to see a specialist for an issue that could have been addressed by their PCP.

Cancer Screenings Warrant Low Co-Pays

Roughly one-third of plans charge no co-pay for cancer screenings, and on average co-pays for cancer screenings are lower than PCP visit co-pays, the analysis found. Although the report raises questions about the cost-effectiveness of low co-pays for some specialist services, “It is encouraging that the data shows good cost incentives for employees to participate in cancer screenings,” said Maureen Cotter, senior principal at HighRoads. “Preventive screenings are an absolutely essential part of an effective wellness program for both employees and employers.”

Stephen Miller, CEBS, is an online editor/manager for SHRM.

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