Bypassing Primary-Care Physicians
Holoweiko, Mark, Medical Economics
HMOs are cooling on the gatekeeper concept. More and more are allowing their enrollees direct access to panel specialists, sometimes with no difference in co-pay Where does that leave you?
"The gatekeeper model is essentially dead," says Peter Boland, president of Boland Healthcare in Berkeley, Calif. "It's an outworn concept, and troubling to many providers. The more sophisticated HMOs have moved beyond the notion of the traditional gatekeeper."
Boland should know. His health-care publishing firm recently put out two fat books analyzing case studies on managed care and reimbursement as practiced by more than 200 companies around the country.
But don't take his word for it. The evidence mounting in the hotbeds of managed care is compelling in its own right:
:Blue Shield of California recently unveiled an "Access+ HMO" that allows patients direct access to specialists within the plan for a $30 copay. (With a primary-care doctor's referral, the copay averages $10.)
:Health Net, a big competing HMO, responded with "Rapid Access," in which enrollees can refer themselves to many specialists within the plan, and "there's no extra charge."
For more than 20 big-ticket procedures and chronic diseases, Oxford Health Plans sends patients directly to specialty teams, which coordinate care and are paid bundled fees.
Minnesota's United HealthCare launched an "Open Access" option that allows HMO enrollees direct access to panel specialists with no difference in copayment. Already, four out of five United members are in such plans (see page 214).
PacifiCare of California came out with "Express Referrals," which lets primary-care physicians bypass utilization reviewers when sending patients to specialists within their practice groups.
MetraHealth Care Plan of Texas Inc. (now United HealthCare of Texas) followed suit with its own version of essentially the same thing, called "Choice."
In northern California, Kaiser Permanente, which boasts that it "has never required health plan preauthorization to see a specialist," has taken things a step further. It's letting adults with muscular or skeletal injuries hobble past primary-care doctors and go right to physical therapists.
Is this good news for doctors, or bad? The answer probably depends on whether you've learned to live with-or even love-those monthly capitation checks, or still find the arrangement burdensome and intrusive.
If you're one who has accepted some of the financial risk of such a plan, well, things just got riskier. On the other hand, HMOs are finally acknowledging that choice of doctor has a high correlation with patient satisfaction. And since that's the ultimate goal of medical care, hey, it can't be all bad.
"'Gatekeeper' is a term that primary-care physicians have never been comfortable with," observes Norman B. Kahn Jr., M.D., director of the division of education of the American Academy of Family Physicians. "It implies keeping the gate closed, when family physicians have always viewed themselves as seeking to provide the best care for their patients."
Others agree. "I think the term 'gatekeeper' has really hurt primary-care physicians in their relationships with the subspecialties," says Archie W. Bedell, president of the Michigan Academy of Family Physicians and chair of the program directors committee in the Ohio Academy of Family Physicians, as well as program director in family practice for Mercy Health System-Northern Region in Toledo. "Truly, we should not block patients' access to needed care. We should be concerned first with taking care of the patient's problem and, next, with doing that in a cost-effective manner."
Internist David B. Nash, director of health policy and clinical outcomes and assistant dean for health policy at Thomas Jefferson University Hospital in Philadelphia, is even more direct: "No one wants to be called a gatekeeper. …