Staff Reporter

After intense pressure from consumers and public officials, a number of health maintenance organizations are allowing their members to see specialists without being referred by a primary care physician although the plans generally cost more and carry some restrictions.

Among the HMOs with large local memberships recently launching "direct access" plans are Health Net, Blue Cross of California, Blue Shield of California, United Healthcare and Kaiser Permanente. Open-access HMO programs are becoming more common in other parts of the country as well.

While primary care doctors are considered medical gatekeepers for more specialized care under managed care networks, the system has come under increased attack for sometimes delaying treatment.

"I think the trend is emerging as part of a patient reaction to the overly restrictive gatekeeping functions that HMOs forced patients to navigate earlier in the decade," said Scott Syphax, associate director of government relations for the California Medical Association. "It also makes good business sense for them. Patients are disgruntled. In order to keep market share, (HMOs) are going to have to respond appropriately. Health care is not a commodity; patients will resist a one-size-fits-all approach."

Added Paul Ginsburg, president of the Center for Studying Health System Change, a Washington-based think tank: "I think the gatekeeper way of managing care will become less important, and HMOs will have to offer more options to stay competitive."

Health Net's just-launched "direct access" plan, dubbed "Elect Open Access," allows members to see any specialist in the 40,000-physician network without a primary care referral. The new program costs about 3 percent to 5 percent more in premiums around $10 to $15 per month more per employee and the member must make a $30 co-payment to the specialist physician.

"People want choice and employers are trying to keep costs down," said Michael Close, senior vice president of commercial sales for Health Net. "(The Elect Open Access plan) meets both those demands and is still cost effective. We think the product is the next generation for the industry."

Blue Shield offers a program that allows its HMO members to opt for direct access with no added premium charges. Members pay a $30 co-payment for direct access to specialists, but their access is limited to only those specialists who belong to the member's chosen medical group. Under the Blue Cross plan, members can see a dermatologist, OB/GYN, ear, nose and throat specialist or an allergist without a referral.

Others are holding back. PacifiCare of California, which has one of the largest enrollments in Southern California, does not have an open-access plan and currently has no plans to introduce one.

Jamie Court, director of Consumers for Quality Care, said patient demand is not the only force driving the move to greater access. HMOs are also trying to preempt any government mandates that may be in store.

"They are trying to get ahead of the game," said Court. "They are creating an argument for when they testify in the Legislature. They will say, 'The market is correcting itself, so new laws are unnecessary.' "

Court added that controlling costs is a lot easier for HMOs if they develop their own programs, rather than wait to have programs mandated for them by government. Under the open-access plans now being introduced, specialists are still paid on a capitated basis (receiving a set, flat monthly amount per patient), so the HMO is able to keep costs down while offering more access. If HMOs were mandated by law to allow members to go to any doctor they wanted, inside or outside the plan, costs would go up.

Initial reaction to the new plans appears favorable, said Bob Vokel, vice president of HCM Benefits Inc. in Torrance, an insurance brokerage firm that represents some 300 employers in the L.A. area.

While they are as much as 5 percent more expensive for customers than traditional HMO plans, they are still less expensive than preferred provider organization plans, which generally allow direct access to specialists.

"I think this is a very good move for the HMOs," said Peng Lauer, benefits administrator for the Fashion Institute of Design and Merchandising, which offers the Blue Shield plan to its 500 employees. "This attracts prospective employees to the company. It is an added feature for us. The No. 1 complaint has been the restrictive nature of HMOs; people like having another option."

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