SPECIALIST CARE: MANY HMOs EASING REFERRAL RESTRICTIONS
The era of the gatekeeper in managed care may be windingThis is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
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,"
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).