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Insurance: Patients Choose Choice

WebMD Health News

May 2, 2001 -- Point-of-service insurance plans may be just what the doctor ordered to bridge the gap between traditional fee-for-service plans and HMOs, according to a new study.

A major attraction to the point-of-service, or POS, plans is that they allow patients to self-refer to another physician or specialist when they see the need. Simply having that option appears to be enough for the vast majority of patients, who tend not to exercise it. This scenario is an attractive one to patients, employers, and insurers alike, as it allows customer satisfaction to remain relatively high, while costs stay relatively low.

"I think our health system is wrestling between the excesses of indemnity insurance -- where people have the traditional fee-for-service insurance and can seek care from any physician at any time -- vs. the tightly-controlled managed care arrangements, where the physician-gatekeeper and the health plan are really controlling patient utilization," lead author Christopher Forrest, MD, PhD, tells WebMD.

"There has to be some middle ground," says Forrest, an associate professor in the department of health policy at Johns Hopkins University's Bloomberg School of Public Health, in Baltimore.

"The POS plan and other similar managed-care models are that middle ground for the health system. It is really a hybrid, an HMO plus indemnity, " he says, allowing managed-care companies and employers to cut costs while giving consumers some degree of personal choice over who provides their healthcare.

While details may vary, POS plan participants generally have three options: Members who use the principal HMO network and obtain authorization for referrals from their primary care physician pay a small co-payment; those who visit a physician within the network, but without a referral pay a bit more; and those who self-refer to out-of-plan practitioners have the most out-of pocket expenses (similar to an indemnity plan).

"Consumers are concerned about being locked into HMO or managed-care arrangements where they can't access specialists," says Forrest.

"The concern was that [a POS] type of plan would lead to a many-fold increase in costs ... ultimately leading to skyrocketing premiums. And our research suggests that this probably is not going to happen. This is a viable alternative for the health system," he adds.

Forrest and his colleagues analyzed statistics for one year from three POS plans around the country that enrolled almost 400,000 people.

They found that only 4-7% of enrollees chose to self-refer to a specialist during that given year, with a similar number self-referring to a generalist during that same time. Thirty-eight percent of those who self-referred said they preferred to directly access specialty care, 28% reported relationship problems with their PCP, and 23% had an ongoing relationship with a specialist. Patients with chronic conditions and orthopaedic patients were more likely to self-refer to a specialist than others.

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