DIRECT ACCESS: Health Plans Open ‘Gate’ Wider

      The "gatekeeper" system, under which primary care doctors refer their patients to specialists when they deem it necessary, "is beginning to open," the Sacramento Bee reports. The new trend has been influenced in part by consumers "who are fed up with the obstacles" to care, and in part by health plans "which have found that improving access to specialists sells." The Bee reports that consumers "hate" gatekeeping: A health rights hotline reported that 40% of its complaint calls in the last 10 months dealt with "delays and denials of care, including specialty care." In fact, health plans that have "direct or easier access" to specialists are seeing "thousands of new enrollees," the Bee reports. However, the new trend "worries a wide range of players in the health care industry -- from medical groups to consumer activists."

Looks Can Be Misleading
      "The day-to-day reality is still the same. It's incredibly hard to get through your gatekeeper and even to see the gatekeeper," said Bruce Lee Livingston, executive director of Health Access, a consumer coalition advocating for a patients' bill of rights in the state. The Bee notes that the "gatekeeper" model was introduced in the early 90s to help "rein in medical costs" -- which it did. But if this model is done away with, some experts worry that direct access will usher back the days of expensive fee-for-service health care. "If you can't find ways of improving access without adding significantly to the cost, you are basically back to unlimited fee-for-service medicine," said California Public Employees' Retirement System spokesperson Bill Branch. And other critics say direct access avoids the root of the problem. "One could argue that open access is an apology for a system that is broken. Our approach is to fix it and make it work right," said Dr. Gordon Norman, medical director of PacifiCare's California division. To compensate for the higher costs associated with allowing patients direct access to specialists, many health plans are placing cost-saving measures on the specialists, or "capitating" them. But medical groups are critical of this practice, worrying "that they will be left holding the bag, since the plans are increasingly shifting the financial risk onto the doctors, who manage the cost of their patients' care." Bill Gil, regional director for the American Medical Group, said, "They (health plans) will advocate open access to everybody and anybody because they are being generous with the medical group's nickel, not with their own."

Can't Get No Satisfaction
      But despite the criticism, several health plans in California are "putting oil on the gate." Blue Shield and United HealthCare allow their California patients to forego the prior authorization requirement to see a specialist if they pay a co-payment or higher premiums. And PacifiCare and FPA Medical Management's Sacramento Community Medical Group offer plans that do away with prior authorization requirements as well. Sacramento-based Western Health Advantage is permitting patients to "self-refer" to certain specialists. However, Blue Shield CMO Ken Prewitt-Wood said, "We're not seeing a dramatic rush to use the direct access features. It's important to have choice, but most people are satisfied with the health care they receive from their primary care physician and the access they have through them to the specialist" (Griffith, 6/1).