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Open Access Publications from the University of California

Health plan switching in anticipation of increased medical care utilization

  • Author(s): Robinson, James C
  • Gardner, Laura B
  • Luft, Harold S
  • et al.

We compare rates and days of maternity and nonmaternity hospital admission for the years 1981 through 1984 for three groups of employees and dependents from a large private employer: those continuously enrolled in a fee-for-service (FFS) plan (N = 147,700), those continuously enrolled in a health maintenance organization (HMO) (N = 30,957), and those switching from the FFS plan to the HMO (N = 2,144). The rate of maternity admissions for plan switchers increased by 106% (P < 0.001) in the post-switch year compared with the pre-switch year, while maternity rates for continuing FFS-plan enrollees declined by 12% (P < 0.001) and rates for continuing HMO enrollees remained unchanged. Nonmaternity admission rates for switchers decreased by 19% (P = 0.079), consistent with the expectation that HMOs reduce these rates substantially, while rates for FFS-plan stayers increased 4% (P < 0.001) and those for HMO stayers remained unchanged. We conclude that employees often switch health plans when anticipating increased needs for maternity care and therefore that pre-switch rates of utilization are unreliable measures of the true magnitude of risk selection between HMOs and FFS plans.

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