Benefits November 2, 2001

Costs Unmoved by HMO "Gateway"

November 2, 2001(PLANSPONSOR.com) - The HMO requirement that patients be referred to specialists by their primary care physicians doesn't have much of an impact on cost, a new study finds.
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The study was based on the Harvard Vanguard Medical Associates HMO, which eliminated its referral, or gatekeeping, system in 1998.

Data on about 60,000 patients, who visited general physicians and specialists while the gatekeeping system was in place, was compared with data on about 30,000 patients who saw general physicians and specialists after the system was eliminated.

While there was only a very small decrease in the average number of visits to primary care physicians and a small increase in the average number of first time visits to specialists after the system was eliminated, there was a large increase in visits to occupational and physical therapists, most notably first visits to specialists for low back pain increased from 26.6% to 32.9%.

Speculation

Researchers speculate that the increase was small because the specialists involved in the study were salaried, rather than paid a fee-for-service, and therefore had less of an incentive to treat a large number of patients.

Another reason may be because the study was conducted less than two years after the system was eliminated perhaps not long enough to allow new patterns to emerge.

Nevertheless, some arguments for gatekeeping rules, which currently affect about half of all patients on HMOs, remain notably the importance of having one physician overseeing care.

Coordination

However the study sends the message that patients and physicians want the process of specialist visits simplified, and many believe that HMOs should provide incentives for primary care physicians and specialists to improve coordination.

One way is to promote widespread and general use of a patient’s medical record access to which would enhance the ability of general physicians and specialists to coordinate medical care a widely held view by industry professionals.

Validation

According to the American Association of Health Plans (AAHP), the study proves that HMOs have been referring patients to specialists at an adequate rate. The association also notes that HMOs are already making it more convenient for patients to get to specialists, pointing out that:

  • some plans have no requirement for a physician referral,
  • others allow a single referral to cover multiple specialist visits, and
  • some allow electronic referrals rather than written requests

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