Which enrollees bypass their gatekeepers in a point-of-service plan?

Barbara L. Braun, Jinnet Briggs Fowles, Christopher B. Forrest, Elizabeth A. Kind, Steven S. Foldes, Jonathan P. Weiner

Research output: Contribution to journalArticle

Abstract

BACKGROUND AND OBJECTIVES. Like Health Maintenance Organizations, point-of-service (POS) health plans use primary care gatekeepers, and they permit self-referral to specialists at increased costs to the enrollee. The main objective of this study was to contrast patients who self-referred with those referred by their primary care physician. RESEARCH DESIGN. We conducted a crosssectional telephone survey of 606 recent users of specialists in a large Midwestern POS health plan; response rate was 65%. We compared 148 enrollees who self-referred with 458 who had a physician referral. RESULTS. Self-referral was most common among those with a long-term relationship with a specialist (odds ratio [OR] = 2.08) and those dissatisfied with their primary care physician (OR = 3.65), and was rare among those with a long-standing relationship with a primary care physician (OR = 0.46). Most self-referred enrollees (68%) thought paying the additional cost for self-referral was worth-while, and they were more dissatisfied with the quality and variety of the plan's specialist network. CONCLUSIONS. Continuity with a single physician influences how patients access specialty care. Expanding the panel of specialists in-network and encouraging long-term relationships with primary care physicians are likely to limit self-referral in a POS plan.

Original languageEnglish (US)
Pages (from-to)836-841
Number of pages6
JournalMedical care
Volume41
Issue number7
DOIs
StatePublished - Jul 1 2003

Keywords

  • Point-of-service
  • Primary care
  • Self-referral

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health

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    Braun, B. L., Fowles, J. B., Forrest, C. B., Kind, E. A., Foldes, S. S., & Weiner, J. P. (2003). Which enrollees bypass their gatekeepers in a point-of-service plan? Medical care, 41(7), 836-841. https://doi.org/10.1097/00005650-200307000-00007