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PRODUCTION CHANGE KICKER TO ‘ACCESS’

By HOWARD FINE

Staff Reporter

So you want to see a top medical specialist, but you’re not a celebrity, you don’t have $20,000 or so to pay for care, or your HMO doesn’t contract with the hot shot you want to see?

Quite possibly, you might be out of luck.

“There aren’t enough top specialists to treat everyone, so not everyone is going to get the absolute best care,” said Dr. William Schwartz, a professor of medicine at USC who has written several books on health care. “In many cases, the patient has to take their destiny into their own hands, and that either means paying out of their own pockets or paying more to get a point-of-service plan.”

That’s not to say that the top specialists cater only to the elite. In fact, almost all take at least some managed care patients; many even take Medi-Cal or uninsured patients.

But given the cost pressures of managed care, many top-level specialists are shying away from heavy commitments to health maintenance organizations, according to Dr. Charles Aronberg, a Beverly Hills ophthalmologist.

“They may not avoid HMOs completely, but they decide to spend less time per patient or cut back on procedures and tests,” Aronberg said.

Nonetheless, HMOs maintain that their enrollees do have access to many of the top specialists in town if their primary care physician determines they need it.

“If you develop a specialized condition that needs treatment, then you can go to any of the 40,000 physicians in our network,” said Dr. Mark Finch, an internist who is charged with ensuring the adequacy and quality of the specialty network for Health Net. “We contract with all nine of the UC campuses, which means, for example, that all of the top specialists at UCLA are in our network.”

To get referred to a specialist, a patient must first get approval from the primary care physician. If the condition is beyond the ability of that specialist to handle, the patient can get referred to a top-level specialist who can handle the case.

But visits to specialists are highly expensive, and HMOs have been criticized for putting limits on such referrals. Though an HMO might not turn down a referral outright, it might reevaluate its contract with a medical group or doctor that makes too many referrals.

For most HMO patients, it’s the initial referral to a specialist that’s the toughest barrier, according to Dr. Ilena Blicker, a Glendale neurologist. That’s because once a patient starts going to a specialist, costs can mount quickly, especially if that specialist orders a new round of tests or ends up referring the patient to another specialist. And HMOs are reluctant to approve those costs.

Denials of referrals to specialists have caused such frustration for patients that consumer groups have made the issue one of their top priorities for health care reform in Sacramento. Employers also have been demanding that their employees have access to specialists.

“When a case is beyond my ability to treat, it can take me a lot to get a patient referred to someone who I think can handle the condition,” Blicker said.

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