 |
|
Self-referral in Point-of-Service Health Plans
Christopher B. Forrest, MD,PhD;
Jonathan P. Weiner, DrPH;
Jinnet Fowles, PhD;
Christine Vogeli;
Kevin D. Frick, PhD;
Klaus W. Lemke, PhD;
Barbara Starfield, MD,MPH
JAMA. 2001;285:2223-2231.
Context Most health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan.
Objectives To comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care.
Design Retrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan.
Main Outcome Measures Self-referred service use and charges, reasons for self-referral, and satisfaction with specialty care.
Results Overall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received.
Conclusions Having the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.
Author Affiliations: Health Services Research and Development Center, Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Md (Drs Forrest, Weiner, Frick, Lemke, and Starfield and Ms Vogeli); and Health Research Center, Park Nicollet Institute, Minneapolis, Minn (Dr Fowles).
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati
What's this?
RELATED LETTER
Factors Affecting Patients' Self-referral to Specialists
John Hsu, Alan S. Go, Joe Selby, Christopher B. Forrest, Jonathan P. Weiner, Klaus W. Lemke, and Barbara Starfield
JAMA. 2001;286(6):672-673.
EXTRACT
| FULL TEXT
RELATED ARTICLE
May 2, 2001
JAMA. 2001;285(17):2263-2264.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Ambulatory Care Provided by Office-Based Specialists in the United States
Valderas et al.
Ann Fam Med 2009;7:104-111.
ABSTRACT
| FULL TEXT
Accounting for Cosmetic Surgery in the USA and Great Britain: A Cross-cultural Analysis of Women's Narratives
Gimlin
Body Society 2007;13:41-60.
ABSTRACT
Do Specialist Self-Referral Insurance Policies Improve Access to HIV-Experienced Physicians as a Regular Source of Care?
Heslin et al.
Med Care Res Rev 2005;62:583-600.
ABSTRACT
The Death of Managed Care: A Regulatory Autopsy
Hall
Journal of Health Politics, Policy and Law 2005;30:427-452.
ABSTRACT
On Being New to an Insurance Plan: Health Care Use Associated With the First Years in a Health Insurance Plan
Franks et al.
Ann Fam Med 2003;1:156-161.
ABSTRACT
| FULL TEXT
Comorbidity: Implications for the Importance of Primary Care in 'Case' Management
Starfield et al.
Ann Fam Med 2003;1:8-14.
ABSTRACT
| FULL TEXT
Primary care in the United States: Primary care gatekeeping and referrals: effective filter or failed experiment?
Forrest
BMJ 2003;326:692-695.
FULL TEXT
Primary care in the United States: Organisation of primary care in the United States
Bindman and Majeed
BMJ 2003;326:631-634.
FULL TEXT
Referral of Children to Specialists in the United States and the United Kingdom
Forrest et al.
Arch Pediatr Adolesc Med 2003;157:279-285.
ABSTRACT
| FULL TEXT
Is the Gatekeeper Useful?
Zarin
AAP Grand Rounds 2002;8:68-69.
FULL TEXT
Family Practice in the United States: A Status Report
Graham et al.
JAMA 2002;288:1097-1101.
ABSTRACT
| FULL TEXT
Integrated Delivery Networks: A Detour On The Road To Integrated Health Care?
Burns and Pauly
Health Aff (Millwood) 2002;21:128-143.
ABSTRACT
| FULL TEXT
Effects of Removing Gatekeeping on Specialist Utilization by Children in a Health Maintenance Organization
Ferris et al.
Arch Pediatr Adolesc Med 2002;156:574-579.
ABSTRACT
| FULL TEXT
Factors Affecting Patients' Self-referral to Specialists
Hsu et al.
JAMA 2001;286:672-673.
FULL TEXT
|
