Emergency Room Visits on the Rise Due to Low Co-Pay Costs But Some Visits May Not be Necessary, According to 2012 Employee

Lower Relative Co-Pays for Urgent Care and Specialists Also Appear to Be Driving More Visits to those Sites, Says Joint HighRoads and Corporate Executive Board Analysis

BOSTON--(BUSINESS WIRE)-- Employees and their families are making more trips to the emergency room (ER), urgent care facilities and specialists’ offices as relatively low co-pay costs are narrowing the gap between those and other services – notably primary care physicians. The trends in employee co-pay are among the latest findings in the 2012 Medical Plan Trends Report conducted by HighRoads and Corporate Executive Board (CEB) (NYSE: EXBD).

According to plan data, the average ER visit co-pay is just $76. The relatively low costs may be leading employees to visit the hospital for symptoms that a primary care physician or other provider could easily and more cost-effectively treat. For example, toothaches and sprains are among the 10 most common conditions for which Americans visit hospital emergency rooms. While some ER visits are also likely attributable to patients who lack insurance, the steady increase in visits appears predominantly to be tied to co-pay costs.

The analysis also found the average plan has a relatively minimal price differential between urgent care, in-network co-pay ($32) and primary care physician (PCP) co-pay ($17). As a result, employees may be choosing urgent care facilities simply for convenience since they tend to keep evening and weekend hours and be open holidays.

Similarly, the price gap between specialists and PCPs is narrowing. From 2010 to 2012 the price differential has dropped from 82 percent to 35 percent higher for specialist visits. 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.

“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,” Ania Krasniewska, senior director, CEB. “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.

In other new data, The Lab found:

  • Roughly one-third of plans charge no co-pay for cancer screenings, and on average, co-pays are lower than PCP visits co-pays.
  • Nearly 40 percent of plans charge low ($10 or less) co-pays for children’s preventive care visits compared to for adults. Almost all employers report that non-employee dependents are responsible for at least 40 percent of the organization’s health care costs.
  • It costs employees nearly twice as much to order a prescription through their plan’s mail order option, compared to visiting a retail pharmacy. While mail-order co-pays are higher, they pay for a greater quantity of the prescription medication (typically 90 days versus the standard 30-day retail prescription).

“It is encouraging that the data shows good cost incentives for employees to participate in cancer screenings,” said Maureen Cotter, Senior Principal, HighRoads. Preventive screenings are an absolutely essential part of an effective wellness program for both employees and employers.”

The findings in this report are the result of the joint study conducted by CEB and The Lab® benchmarking repository of health care benefit plan data, covering more than 34 million lives and representing more than 12,000 plans.

For a copy of the report please contact Petra Marino at [email protected].

About HighRoads

The world’s leading employers choose HighRoads to gain complete control over their health care costs and compliance. With HighRoads’ service, employers have online access to benefits plan information and pricing, competitive benefits benchmarks, and complete benefits management. The privately-held company is headquartered in Woburn, MA. For more information, visit www.HighRoads.com.


HighRoads Company Contact:
Petra Marino, 781-503-4031
[email protected]
HighRoads Media Contact:
Erin Jones, 704-664-2170
[email protected]

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INDUSTRY KEYWORDS:   Practice Management  Health  Hospitals  Other Health  Managed Care