BY STEPHENIE OVERMAN

Contributing Reporter

As criticism mounts about the sometimes limited access to specialists, HMOs are beginning to open up the process. But state and federal legislation might open it up even further.

There's been "a huge problem with patients getting necessary referrals, getting to specialists," said Jamie Court, director of Consumers for Quality Care in Santa Monica.

Many managed care groups have discouraged a primary care physician from referring patients to specialists, according to Court.

In some cases, "we're also seeing the capitation of specialists," said Court, referring to the practice of HMOs paying specialists a flat per-patient monthly fee. Critics argue that this effectively encourages physicians to provide only the minimum level of care.

"(Specialist capitation) is a relatively new phenomenon, but it's a dangerous situation," Court said. At the point where patients are sick enough to need a specialist, "their doctors shouldn't be incentivized not to give them all the care they need."

HMOs have begun responding to marketplace demands as well as political pressure to allow quicker referrals.

HMOs "started to respond" to criticism two years ago and have been working ever since to give patients easier access to specialists, said Myra Snyder, president and chief executive of the California Association of Health Plans, an HMO trade group.

Some HMOs have begun expediting the review process, according to Snyder. "They've put referrals to specialists on the fast track" by requiring fewer preconditions, she said.

Blue Shield of California is among the first plans to allow self referrals within the medical group of the enrollee's primary care physician. For example, if an enrollee's primary care physician belongs to a medical group that has cardiologists, neurologists and urologists, patients could "self refer" to any of those specialists without being referred by their primary care physician, but would have to pay slightly more, she said.

"There's been a positive response from consumers" to this intra-network approach, she added.

The other improvement in access has been in female patients' direct access to obstetricians and gynecologists.

Almost all health plans allow women to make an annual visit to their obstetrician or gynecologist without having to go through the referral process, according to Snyder. "The only caution we have is that a woman should not be using an ob/gyn for primary care, unless the ob/gyn is trained as a primary care physician," she added. "We've heard the complaints and it comes down to an issue of choice. People want to have a choice, even if they don't use it."

For reprint and licensing requests for this article, CLICK HERE.

Prev