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Primary Care/Managed Care

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Having a regular site of care but not a regular personal physician does not adversely affect access to care

Individuals who have a regular site of care, such as a health maintenance organization (HMO), clinic, or multispecialty group practice, use primary care services such as immunizations and cancer screening tests as much as individuals who have a regular personal physician, according to a recent study. This suggests that the "impersonal care" at these sites, where a person may see a different doctor at each visit, may not negatively affect primary care use. However, individuals whose regular source of care is a non-mainstream site—such as a hospital outpatient department or emergency room, family health center, or walk-in center—may not use primary care services as often as those who have mainstream sites of care or regular doctors, notes Gordon H. DeFriese, Ph.D., of the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.

The researchers, who were supported by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00032), used the 1987 National Medical Expenditure Survey, a household survey of health care use and expenditures by 35,000 noninstitutionalized individuals, to examine patterns of primary and preventive health care use by individuals with regular sources of care. Analyses showed that the general use of physician services was higher for those with a regular doctor (83 percent) than for those with a regular site but no regular doctor (72 percent) and those with no regular source of care (65 percent).

However, the apparent advantage of having a regular doctor over a regular site disappeared when only those individuals reporting a physician's office, clinic, or HMO as their regular source of care were compared, leaving out non-mainstream sites of care. The researchers suggest that this difference in use of primary care may have been caused by characteristics of the non-mainstream sites of care as well as their inability to promote a doctor-patient relationship.

For details, see "The effects of having a regular doctor on access to primary care," by Jeanne M. Lambrew, Ph.D., Dr. DeFriese, Timothy S. Carey, M.D., M.P.H., and others, in the February 1996 issue of Medical Care 34(2), pp. 138-151.

Research needed on the impact of selective contracting and freedom-of-choice laws on managed care plans

Any willing provider (AWP) laws require managed care plans to accept any qualified health care provider who is willing to accept the terms and conditions of the plan, even though the plan does not have to contract with all providers. Freedom of choice (FOC) laws permit a person enrolled in a managed care plan to be reimbursed for health care services from any qualified provider, even if the provider has not signed a contract with the managed care plan (selective contracting). These laws usually require managed care plans to pay the same amount to a non-network provider chosen by an enrollee as they pay to a network provider, but this does not guarantee that the enrollee will incur the same out-of-pocket costs.

Today 33 States have passed either AWP or FOC laws, yet there is little evidence of their impact on managed care plans, notes Fred J. Hellinger, Ph.D., of the Agency for Health Care Policy and Research's Center for Organization and Delivery Studies. He discusses the effect of these laws on HMO administrative costs, the price health plans pay to health care providers, and the use of health services.

AWP and FOC laws also limit the ability of managed care plans to funnel patients to specific providers, thus lessening their power to obtain volume discounts. One study shows that staff- and group-model HMOs reduced enrollees' health spending by 15 percent compared with traditional indemnity insurance, with half of this reduction due to price discounts.

Dr. Hellinger notes the lack of any studies on the impact of FOC laws and the sparse and limited nature of studies focusing on AWP laws. He cites in particular the need for studies that compare the experiences of health plans in States with and without comprehensive laws. Until convincing evidence about the impact of AWP and FOC laws on the cost and quality of care is available, policymakers will have to rely on their own judgment when weighing the advantages and disadvantages of this legislation, concludes Dr. Hellinger.

See "Any-willing-provider and freedom-of-choice laws: An economic assessment," by Dr. Hellinger, in the Winter 1995 issue of Health Affairs 14(4), pp. 297-302.

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