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Health Care Costs and Financing

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Direct patient access to specialists does not lead to more specialty visits in plans with modest cost-sharing arrangements

The potential overuse of specialists has been a major cost-cutting target of managed care organizations. Traditional health maintenance organizations (HMOs) permit access to specialists only with authorization from a primary care provider (PCP)/gatekeeper and/or plan administrators. However, growing numbers of patients are enrolling in preferred provider organizations and point-of-service (POS) HMOs, which allow patients direct access to specialists. According to a recent study, individuals who have direct access to specialists in POS HMOs do not make more visits to specialists than individuals enrolled in gatekeeper HMOs. The study was supported by the Agency for Healthcare Research and Quality (HS09414).

Researchers led by Jose J. Escarce, M.D., Ph.D., of the RAND Health Program, estimated the number of PCP and specialist visits for 16,192 working-age members of a gatekeeper HMO and 36,819 working-age members of a POS HMO. Gatekeeper HMO members had 35 percent more PCP visits and 33 percent more total visits than people in the POS HMO. However, POS HMO members had no more specialist visits than members in the gatekeeper HMO. What's more, only one-sixth of specialist visits for POS HMO members were obtained through patient self-referral.

The rules governing the gatekeeper HMO may actually induce additional visits to both PCPs and specialists. For example, patients in the gatekeeper HMO had to see their PCPs before they could receive most services, and patients who see their PCPs more often have more opportunities to receive referrals to specialists. Also, monitoring PCPs and maintaining authorization procedures are costly, and these costs may offset any cost savings from reductions in specialty care, note the researchers.

See "Visits to primary care physicians and to specialists under gatekeeper and point-of-service arrangements," by Geoffrey F. Joyce, Ph.D., Kanika Kapur, Ph.D., Krista A. Van Vorst, M.S., and Dr. Escarce, in the November 2000 American Journal of Managed Care 6, pp. 1189-1196.

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