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Study: HMO Gatekeeping Doesn't Cut Costs

No change in specialist visits when requirement eliminated

WEDNESDAY, Oct. 31, 2001 (HealthDayNews) -- Gatekeeping -- the requirement by a health maintenance organization (HMO) that patients get a referral from a primary care physician to see a specialist -- didn't save much money, a Harvard study finds.

The number of visits to specialists did not increase after the Harvard Pilgrim Health Care HMO eliminated the need for referrals in 1998, say researchers led by Dr. Timothy Ferris, a senior scientist at the Massachusetts General Hospital Institute for Health Policy.

Ferris and his colleagues found the average number of visits to specialists for the six months before and after the change was identical. The most notable change was an increase in first visits to specialists for low back pain, from 26.6 to 32.9 percent. The findings appear in the Nov. 1 issue of The New England Journal of Medicine.

"Because the cost and inconvenience of gatekeeping to physicians and patients are great, we may want to re-evaluate the policy," Ferris says.

But the fact that gatekeeping apparently does not lower medical costs, the primary reason for its adoption, doesn't mean it should be abandoned entirely, Ferris says.

"We shouldn't throw the baby out with the bath water. There are some elements, particularly those that enhance the coordination of care, that need to be strengthened and retained," he says.

Because patients are likely to benefit, Ferris says HMOs should "start with some incentives for primary care physicians and specialists to improve coordination. One way is to promote widespread and general use of a patient's medical record. Access in real time to the record would dramatically enhance the ability of general physicians and specialists to coordinate medical care."

Speaking for the American Association of Health Plans, which represents more than 1,000 organizations covering 150 million Americans, spokeswoman Susan Pisano says the study indicates that one major complaint, that HMOs deny patients access to specialists to reduce costs, is unwarranted.

She says the study's finding validates what HMOs have been doing. "The study indicates that physicians in health plans have been opening up the system and referring patients to specialists at an adequate rate," Pisano says.

She cites a movement away from gatekeeping. "Health plans are using a variety of approaches to make it more convenient for patients to get to specialists." Some plans have no requirement for a physician referral, others allow a single referral to cover multiple specialist visits, and some allow electronic referrals rather than written requests, she says.

Like Ferris, she says gatekeeping has some benefit for patients. "The coordination of care and the patient safety element continue to be important even in the absence of savings," Pisano says. "The importance of having one physician overseeing care does not diminish in time, but there is a clear message that patients and physicians want the process of getting to see a specialist kept as simple as possible."

Ferris says gatekeeping rules on specialist visits affect about half of all patients in HMOs.

What To Do

Any patient who visits a specialist, with or without a referral, should ask whether the information gathered by the specialist is shared with the primary care physician.

Information about the policies and practices of HMOs is offered by the American Association of Health Plans and the Health Insurance Association of America.

SOURCES: Interviews with Timothy Ferris, M.D., senior scientist, Massachusetts General Hospital Institute for Health Policy, Boston, and Susan Pisano, spokeswoman, American Association of Health Plans, Washington, D.C.; Nov. 1, 2001 The New England Journal of Medicine
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