Good news for specialists: The gate is swinging open
Good news for specialists: The gate is swinging open
Payers respond to consumer demand for access
Now that health care experts are predicting the demise or at least the relaxation of managed care policies requiring consumers to go through a primary care physician before seeing a specialist, groups around the country are anxious to see if the change will fly. Physician’s Managed Care Report first informed you about this trend last year (see story in PMCR, December 1996, pp. 139-141), and we thought it would be helpful to revisit two health plans that have altered their specialty access policies due to consumer demand.
The consensus: Consumers are responding overwhelmingly in favor of a health plan favoring open access by voting with their feet, say representatives from Santa Ana, CA-based PacifiCare of California and San Francisco-based Blue Shield of California.
Blue Shield’s Access Plus product which allows direct access to a specialist within the medical group or independent practice association that employs a consumer’s primary care physician, but at a higher copay rate has seen a 32% growth rate in membership for the 12 months ending March 31, 1997, says Ken Pruett-Wood, senior vice president and chief marketing officer of Blue Shield. Medical groups that chose to participate in Access Plus have seen a 39% growth rate in patient load from Blue Shield, whereas groups that participate in other Blue Shield networks but did not sign on with Access Plus experienced a 5% patient growth rate from the payer’s membership, he says.
However, a relatively small number of Blue Shield members less than 2% are actually exercising the open access option, leading Blue Shield executives to believe that the open access benefit is primarily a psychological one. "It’s the security of knowing it’s there," Pruett-Wood says. "Many consumers feel disempowered in an HMO setting as not being part of the decision-making process. They want the ability to exercise the [open access] approach."
Consumer preference for easier access to specialists also is evident at PacifiCare, whose Express Referral product guarantees consumers a specialist referral immediately to one of 16 specialties, after first seeing a primary care physician (PCP), and within 24 hours for all other referrals if their PCP is part of the Express Referral network. Patient growth rate among medical groups or independent practice associations that are part of the Express Referral network was 50% higher than the balance of practices in PacifiCare’s other physician networks, compared with a 25% higher enrollment rate among these same group of practices in 1996, says Wendy Kuran, director of plan providers. Members also can access specialists directly through a point-of-service product, which is common to many health plans.
Committees authorized 98% of referrals
"We are not unraveling the gatekeeper process, but empowering the gatekeeper," Kuran says. "In our pilot study of the [Express Referral] program, we found that 98% of the specialist referrals the practice’s PCPs were submitting to our authorization committee were being approved. So we figured, why were we spending all this money to validate that decision and holding the patient hostage in the process?"
PacifiCare originally included large group practices and independent practice associations the payer had a long history of working with in the program, but it has expanded the number of groups in the network effective Jan. 1, Kuran says. The 16 specialties no longer requiring authorization include: cardiology, dermatology, endocrinology, ear, nose and throat, gastroenterology, general surgery, hematology, neurology, obstetrics/gynecology, oncology, ophthalmology, orthopedic surgery, pediatric surgery, podiatry, routine X-ray, and urology.
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