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Tuesday, Sep 26, 2023



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.”

At PacifiCare of California, primary care physicians until recently needed approval from the health plan or medical group before referring a patient to a specialist, said Cheryl Brady, a PacifiCare project manager. “But 80 or 90 percent were being approved, so we’ve eliminated that step. Now the primary physician can automatically refer within the network. It saves some time and has been working very well.”

PacifiCare’s new practice, called Express Referral, began as a pilot program in California and is now being rolled out to other parts of the United States, Brady said.

The program Blue Shield launched in June to increase its enrollees’ access to specialists, called Access+HMO, is “pretty simple and very effective,” said spokeswoman Lisa Citron. It allows members to directly access specialists from the medical group to which their primary care physician belongs.

Despite the improved access, legislative efforts are underway in California that would actually mandate the process.

Assemblywoman Liz Figueroa, D-Fremont, is looking to override Gov. Pete Wilson’s veto last year of Assembly Bill 794, or fold the bill’s provisions into a new bill this year. AB 794 would prohibit a health care plan from “refusing to authorize heath care services determined to be medically appropriate and necessary by the patient’s physician,” the bill states.

National leaders are looking at two slightly different versions of legislation guaranteeing access to specialists, according to John Stone, a spokesman for Rep. Charlie Norwood, R-Ga.

Norwood has sponsored a bill that would give “guaranteed access to a specialist on the advice of the treating physician. It does not give blanket approval for everybody out there. But if you go to your regular doctor, and if it’s serious enough, you will be referred,” Stone said.

A reform measure supported by President Clinton would go a little further, Stone said, by mandating that female patients be allowed to choose obstetricians and gynecologists as their primary care providers.

Guaranteed access to specialists “is one of the hot-button areas of reform this year,” Court said. “More and more patients realize how important it is because they have heard horror stories about what happens to people who don’t get to specialists in time. If a patient has cancer, time is of the essence. But the system is full of delays and checks. People are worried that it will cost them time they don’t have.”

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