Majority of Patients in Point-of-Service Health Plans Never Use Self-Referral Option for Specialty Care

Study Suggests Ability to Bypass Gatekeepers Does Not Lead to Overuse of Services

A rapidly growing trend in health insurance is the point-of-service (POS) plan, which allows members to seek specialty services for a fee without first consulting with their primary care physician, or plan gatekeeper. However, the majority of patients enrolled in POS plans never use their self-referral option, according to a study by researchers at the Johns Hopkins Bloomberg School of Public Health. In addition, the few patients who did self-refer reported being more satisfied with their specialist than patients who were referred to a specialist by their physician.

The study is the largest and most comprehensive analysis of POS health insurance plans in the United States. The findings, which appear in the May 2, 2001 issue of the Journal of the American Medical Association (JAMA), suggest that the self-referral option for patients does not lead to uncontrolled use of specialty health services as many managed care companies once feared.

"One of the greatest sources of consumer dissatisfaction with today’s health maintenance organizations (HMO) is the perceived barrier to specialist care. Simply having the option to bypass the so-called gatekeepers of managed care seems to be enough for most people in point-of-service health plans," says Christopher Forrest, MD, PhD, lead author of the study and associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.

The POS plan, or open-HMO, is a combination of the traditional HMO, preferred provider network, and fee-for-service plans. POS plan members pay minimum fees for service within the network and for referrals authorized by the physician gatekeeper. The member’s share of the cost increases for treatment outside the network and for self-referrals. According to the study, a family POS plan costs employers and workers an additional $635 per year compared to a traditional HMO.

For the study, the researchers analyzed data from three POS health plans located in the Midwest, Northeast, and Mid-Atlantic regions. The analysis looked at nearly 500,000 plan members enrolled for a six to 12 month period in 1996. Investigators also conducted a telephone survey of 600 people in the Midwest plan that had received care from specialists.

Over all the study found, only four to seven percent of POS members exercised their self-referral option to see a specialist physician. Patients with unstable chronic conditions, allergies, orthopedic problems, and injuries were the mostly likely to self-refer for care. When patients did self-refer, they were slightly more likely to visit a generalist than a specialist. The most popular specialists selected were dermatologists and orthopedic surgeons.

Of enrollees who chose to self-refer for treatment, 38 percent said they did so to save time and to choose their own specialist. Another 28 percent said they self-referred because they did not get along with their regular doctor, most often because the doctor refused to grant a referral to a specialist. Twenty-three percent said they had an on-going relationship with a specialist, eight percent were confused by the insurance company rules, and three percent said they did not have a primary doctor.

In addition, the study also found that only 16 to 20 percent of the charges to the insurance companies were from patient self-referrals. Most patients who self-referred for specialty care were more satisfied with the physician they chose compared to patients treated by doctors pre-approved by the insurance gatekeeper.

"Our research shows that loosening the gatekeeper’s restrictions does not lead to uncontrolled use of specialty services. The potential downside is counterbalanced by the greater patient satisfaction, " explains co-author Jonathan P. Weiner, PhD, professor and deputy director of the Health Service Research and Development Center at the Johns Hopkins Bloomberg School of Public Health. "The self-referral option is like flood insurance for your home. You hope you never need it, but you feel better knowing that it's there," adds Dr. Weiner.

Jinnet Fowles, PhD, Christine Vogeli, Kevin D. Frick, PhD, Klaus W. Lemke, PhD, and Barbara Starfield, MD, PhD, contributed to the research of this study.

The study was funded by a grant from the Robert Wood Johnson Foundation.