Clinical Utilization by Uninsured Workers in a Contributory Health Plan

Brief communication 169 CLINICAL UTILIZATION BY UNINSURED WORKERS IN A CONTRIBUTORY HEALTH PLAN The need to provide medical care to uninsured workers is a challenge not easily met. Those who wish to implement provisions for medical access for this underserved group face not only obvious financial roadblocks but a daunting lack of information about the potential needs of the uninsured. A widely held perception that extended periods without health insurance or medical access could only enhance the potential for massive overutilization, when health care access is obtained, has recently been challenged.1 While estimates of utilization within the context of a large health maintenance organization (HMO) are very useful, there are other important paradigms for provision of health care to the uninsured. In this report the utilization experience in a contributory health plan (CHP) is described. The Minimum Wage Employees Plan for Health Insurance Services The Minimum Wage Employees Plan for Health Insurance Services (MEMPHIS) is a CHP that was developed by the Church Health Center of Memphis to provide access to health care for workers who do not have health insurance. The providers are family practitioners, internists, and pediatricians who contribute primary care clinical "slots" on a strictly voluntary basis, for the care of MEMPHIS enrollees and their families. Specialists, including gynecologists, also contribute as slots are needed. In-patient services are contributed by a local hospital at no charge to the patient. Employers who wish to allow their employees to enroll must offer it to all of their income-qualified employees and pay at least $10 per month of each employee's premium. Premiums range from $35 per month for a single employee to a maximum of $95 per month for a family. Employers that use this CHP include large restaurants and security companies as well as small service businesses, individual households employing domestic workers, and the self-employed. Table 1 summarizes the scope of MEMPHIS both cumulatively, since its inception in August 1991, and at one recent (February 1997) time point. The purpose of this study is to determine the nature and extent of utilization of the primary care slots by the 249 individuals (employees and their spouses) who were enrolled for at least six consecutive months from October 1,1995 until September 30,1996. This information should be useful to providers who are Journal of Health Care for the Poor and Underserved · Vol. 10, No. 2 · 1999 170 Contributory Health Plan TABLE 1 CUMULATIVE AND RECENT MEMPHIS" PARTICIPATION ENROLLEES EMPLOYERS PHYSICIANS Since inception (1991) 1,662 354 188 February 1997 797 190 172 a MEMPHIS = Minimum Wage Employees Plan for Health Insurance Services. considering participation in a CHP or to those who may be considering such an undertaking in their community. Method MEMPHIS participants were eligible for this study if they were enrolled for at least six months during the period beginning on October 1,1995 and ending on September 30,1996. Thus, those who enrolled after April 1,1996 or did not have six months of continuous enrollment during the study period were excluded from the study. The physician to which each of the eligible enrollees was assigned was identified and a listing of potential patients created for each physician. These physicians were contacted in December 1996, first by man, and later by telephone if necessary, and asked to provide utilization information for each patient listed. Specifically, the physicians were asked to indicate whether or not the identified enrollees had been seen at their clinic. If the enrollees had come to the office, the physician was asked to forward a copy of the office notes for all visits between October 1,1995 and September 30,1996 to the Church Health Center. As these records were received, the primary referee reviewed the information and determined up to four diagnoses for each office visit. The reviewer also recorded whether or not laboratory, radiology, or electrocardiograms were ordered as a result of the visit and any referral was also noted. International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to each diagnosis by the primary referee. After about one-half of the requested records had been received, 12 records were chosen at random for independent diagnostic...