SPECIALIST CARE: MANY HMOs EASING REFERRAL RESTRICTIONS

      The era of the gatekeeper in managed care may be winding
 down, NEW YORK TIMES reports.  Many HMOs that now require
 patients to receive a referral from their primary physician
 before seeing a specialist "are trying to simplify and speed up
 the process," TIMES reports.  And, while "many experts say the
 jury is still out on whether easier access to specialists will
 necessarily be followed by higher costs, some HMOs are taking no
 chances and are charging more for plans that allow visits to
 specialists without prior permission."  Under such plans,
 patients pay up to 15% more in monthly premiums or pay an extra
 fee each time the nonreferral option is used.
      BACKDOOR BUSINESS:  TIMES reports that "some HMOs have
 merely moved the responsibility for permission to another party: 
 the specialist."  In such cases, the patient may visit a
 specialist without a referral, but that doctor must then obtain
 permission from the insurance company before giving care or
 ordering tests.  "It's a backdoor kind of gatekeeper," said Rich
 Sinni, a benefits expert with Buck Consultants.  "Backdoor or
 not, HMOs without unrestricted visits to specialists take patient
 empowerment a step beyond another popular group of managed health
 plans, those that permit members to go to specialists of their
 choice even if they are outside a prescribed network of doctors,"
 TIMES reports.
      WORKING SYSTEM?:  Some HMOs are questioning the cost-saving
 effectiveness of the gatekeeper/restrictions system.  John Erb, a
 health care consultant with Foster Higgins, said, "I'm not sure
 when you look at the administrative cost, whether in fact the
 gatekeeper saves any money."  TIMES reports that "[m]anaged care
 experts say HMO members usually go to their primary care doctors
 for 80 to 90% of their medical needs anyway," adding that "while
 many patients complain about access to specialists, the HMOs say
 that access is nearly always approved." 
       BACKLASH:  A "backlash" has taken place over the past two
 years in which "at least 17 states ... have ordered health plans
 to provide direct access to certain specialists."  And, according
 to the TIMES, some plans "are coming to see the value of looser
 rules."  Margaret Stanley, a health care executive with the
 California Public Employees Retirement System, said, "As managed
 care gets to be a bigger and bigger percentage of the market, we
 need to make it more and more acceptable to more people."  TIMES
 reports that United HealthCare, which covers 1.7 million people
 in 18 states, "says it will introduce" HMOs with looser
 restrictions this year in California and seven other states.  New
 York-based Physician Health Services added 75,000 "open access"
 members in the past 18 months, and other "big health insurers,"
 such as Prudential Healthcare, Aetna, and Health Systems
 International, "are also looking at offering HMOs without
 restrictions on visits to specialists," TIMES reports.  According
 to a 27-city survey of 85,000 health plan members last year, 30%
 of respondents said they were not satisfied with the specialist
 referral process (Freudenheim, 2/2).