SPECIALIST REFERRALS: MANY HMOs ARE CHANGING THEIR SYSTEMS
HMOs are "finally addressing a major patient complaint:This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.
referrals," WALL STREET JOURNAL reports. Some HMOs are using new
technology to approve specialist referrals "almost instantly,"
while other companies are loosening or entirely eliminating the
stringent rules governing referrals.
ANECDOTAL EVIDENCE: Because referrals were the "major
source of patient dissatisfaction," Monarch Health System now
allows its 175 primary care doctors to refer patients to network
specialists without prior approval for all but the "most costly
or controversial treatments." The company made the move in part
because 99% of referral requests were approved in the first
place. Since it made the policy change, JOURNAL notes that
Monarch's "referrals haven't jumped." Monarch estimates that the
changes brought administrative savings of $200,000. PacifiCare
Health Systems, Inc. is studying Monarch's changes with a "view
toward 'exporting' them throughout its system." PacifiCare
Southern California Regional Vice President and General Manager
Chris Wing said, "Some rules that made sense 10 years ago when
physicians were learning how managed care works no longer add
value in the fourth generation of this revolution."
ELECTRONIC REVOLUTION: Blue Cross and Blue Shield of
Massachusetts has installed a new computer network called
"Healthwire" in 6,700 doctors' offices, which allows physicians
to get almost instant approval of their specialist referrals.
Prudential Insurance Co. of America has given "swipe boxes" to
2,000 doctors in three states and plans to expand the practice
across the country. The machine, which is similar to credit card
approval devices, allows doctors to type in a patient's diagnosis
and referral information. In seconds, a receipt prints out with
patient eligibility confirmation, referral approval and charges
for services rendered.
FOLLOW THE LEADER: Because Prudential has saved about $2
million so far -- the $0.25 to $0.60 cost is "a fraction" of the
$6 to $12 costs of manual processing -- companies including
Oxford Health Plans and U.S. Healthcare say they "will use [the
system] soon." Cigna Corp. is the only other managed care
company currently using swipe machines.
IS THIS MANAGED CARE?: United HealthCare Corp. has said
that its "Open Access" plan, which doesn't require specialist
referrals, is the company's "fastest growing product." United
Senior Vice President Blair Suellentrop said, "We grew 44% in
five states in the last 12 months, virtually all in Open Access"