title: Solution to patient access to specialist care lies in a balanced approach.
abstract: Managed care economic and administrative measures designed to coerce "gatekeepers" to limit patients' access to specialist care need to be balanced by sound clinical protocols. Balance is maintained when appropriateness of care, not costs, guides care and referral decisions. This article explores how appropriateness can be achieved through the use of clinical decision support criteria or guidelines. Not only do the guidelines enable providers to deflect demand appropriately and prevent unnecessary interventions, they help mitigate the financial risk that providers assume under managed care.
authors.affiliation: InterQual, Marlborough, MA, USA.
authors.forename: T
authors.initials: T
authors.lastname: Hongsermeier
mesh_terms: D002985:Clinical Protocols; D003661:Decision Support Techniques; D018588:Fee-for-Service Plans; D017408:Guidelines as Topic; D006297:Health Services Accessibility / Q000592:standards*; D006801:Humans; D008329:Managed Care Programs / Q000191:economics / Q000458:organization & administration / Q000592:standards*; D008511:Medicine; D012017:Referral and Consultation / Q000592:standards* / Q000706:statistics & numerical data; D013038:Specialization; D014481:United States