Forrest says he was surprised by how few people are self-referring to a specialist.
"A POS plan costs about $600 ... more per year than an HMO plan, so you'd think that if you were purchasing that option to self-refer, you would to use it," he tells WebMD. "But it turns out people use it like homeowner's insurance: It's a safety net. And that really is the take-home message: People have these options to self-refer and they are not using them.
Ken Thorpe, PhD, professor of health policy at the Rollins School of Public Health at Emory University in Atlanta, says he also is surprised at the low number of self-referrals.
"One interpretation is that people felt comfortable knowing they could refer out," he says.
Another explanation, Thorpe says, could be that the people who are more inclined to refer themselves to specialists opted to join an indemnity plan (if it were available to them). Or perhaps, he says, the in-network choices are fairly broad, so people wouldn't have to refer themselves out-of-network as often.
"To really get a better handle on [the study findings] we would have to know more about the enrollees' choice of plans," he says.
Despite these questions, Thorpe says that POS plans are a happy medium and that is why they are the fastest-growing model in healthcare insurance. They provide some check on expenditures, while at the same time they don't reduce the satisfaction that patients may have with their health plans that much."
The bottom line, says Thorpe is choice -- choice within a plan, but especially choice between plans.
"We know from other studies that, to the extent that people have broader choices of plan designs available to them, they are going to be happier ... because you are giving people the opportunity to sort into the plan they are the most comfortable with."
Forrest's study appears in the current issue of the Journal of the American Medical Association.