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Managed Care

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Providing patients with direct access to specialists does not necessarily increase medical expenditures

Individuals in point-of-service (POS) health insurance plans have direct access to specialists, while those who belong to traditional health maintenance organizations (HMOs) must first see their primary care physician (PCP) who acts as a "gatekeeper" to approve or disapprove referral to a specialist. This gatekeeper approach has been used by HMOs as one way to reduce high specialty care costs. However, the direct access to specialists provided to individuals in a POS plan who shared the same network of providers as enrollees in an HMO plan did not result in higher medical expenditures, according to a recent study supported by the Agency for Healthcare Research and Quality (HS09414).

When enrollees are required to choose PCPs, as they were in both the POS and HMO plans in this study, patient cost-sharing, physician financial incentives, and utilization review may control expenditures without the need to constrain direct patient access to specialists, explains Jose J. Escarce, M.D., Ph.D., of the RAND Health Program. Dr. Escarce and his colleagues used administrative data files for the HMO and POS plans for 1994 and 1995 to assess total medical care expenditures and spending for various health services.

Overall, 87 percent of HMO enrollees and 78 percent of POS enrollees used some type of medical care annually. Total expenditures for medical care, including office visits, hospitalizations, outpatient hospital services, and prescription drugs, ranged from equal in both plans to 7 percent higher in the gatekeeper HMO, depending on the copayments for physician visits. The findings were similar for enrollees with or without chronic conditions. For example, total medical care expenditures for healthy enrollees in the HMO and POS plans with no copayments for PCP and PCP-referred specialist visits were predicted to be $1,050 and $1,037, respectively. For $10 copayments, the predictions were $1,057 and $909, respectively.

More details are in "Medical care expenditures under gatekeeper and point-of-service arrangements," by Dr. Escarce, Kanika Kapur, Ph.D., Geoffrey F. Joyce, Ph.D., and Krista A. Van Vorst, M.S. in the December 2001 Health Services Research 36(6), pp. 1037-1057.

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