title: Self-referral in point-of-service health plans.
abstract: BACKGROUND
  Most health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan.
  
  
  OBJECTIVE
  To comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care.
  
  
  METHODS
  Retrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan.
  
  
  METHODS
  Self-referred service use and charges, reasons for self-referral, and satisfaction with specialty care.
  
  
  RESULTS
  Overall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received.
  
  
  CONCLUSIONS
  Having the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.
authors.affiliation: Health Services Research and Development Center, Johns Hopkins School of Public Health, 624 N Broadway, Room 689, Baltimore, MD 21205USA. cforrest@jhsph.edu
authors.forename: C B
authors.initials: CB
authors.lastname: Forrest
authors.forename: J P
authors.initials: JP
authors.lastname: Weiner
authors.forename: J
authors.initials: J
authors.lastname: Fowles
authors.forename: C
authors.initials: C
authors.lastname: Vogeli
authors.forename: K D
authors.initials: KD
authors.lastname: Frick
authors.forename: K W
authors.initials: KW
authors.lastname: Lemke
authors.forename: B
authors.initials: B
authors.lastname: Starfield
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D004470:Economics, Medical; D005245:Fee Schedules; D005260:Female; D019538:Health Care Surveys; D006279:Health Maintenance Organizations / Q000191:economics / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D008297:Male; D008511:Medicine / Q000592:standards; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000191:economics / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013038:Specialization; D014481:United States