National HMO Enrollment by State

December 1, 2005

HMO penetration analyses by state are affected by a number of factors, say industry experts. They include: employer offerings; employee incentives: the mix of commercial, Medicare and Medicaid enrollees; and national employers listing enrollment by home state rather than where enrollees live.

"With these limitations, my impression is that a potential cause of the small decline overall nationally, and in particular in the state with the largest enrollment, is the shifting of enrollees from HMOs into consumer-driven, high-deductible health plans," according to Joseph M. Mack, MPA, senior vice president at the National Healthcare Practice in the Irvine, Calif., office of Beecher Carlson, an Atlanta-based insurance brokerage and risk management firm. "These plans typically pay as a PPO rather than an HMO. Consequently, as employees shift from HMOs to consumer-driven plans, there is a decline in total HMO enrollment."

Pay for performance

"If this is true, then lower performing groups actually are spending more time and money to comply with pay for performance, only to receive a lesser portion of the incentive income because they were originally performing below the mean," he says. "Physicians have to ask themselves if it makes business sense to continue to participate in such programs if they have to invest capital . . . to comply and report pay-for-performance measures, or if there are other reimbursement programs . . . that will pay them more than they receive from HMOs, with little or no change to their existing practices."

-Tracey Walker