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Health Care Reform:

Health Insurance & Affordable Care Act

Insurance: Patients Choose Choice

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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.

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."

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