Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study.
OBJECTIVE
The specialty referral process is one of the chief targets of managed care constraints on ambulatory medical decision-making. This study examines the influence of gatekeeping arrangements and capitated primary care physician (PCP) payment on the specialty referral process in primary care settings.


METHODS
Primary care practice-based study of referred and nonreferred office visits.


METHODS
The study comprised 14,709 visits made by privately insured, nonelderly patients who were seen by 139 primary care physicians in 80 practices located in 31 states.


METHODS
Visits were grouped by health plan type: gatekeeping with capitated PCP payment; gatekeeping with fee-for-service PCP payment; no gatekeeping. Dependent measures included the proportion of visits referred, characteristics of referrals, and physician coordination activities.


RESULTS
The percentages of office visits resulting in a referral were similar between the two gatekeeping groups and higher than the no gatekeeping group. Patients in plans with capitated PCP payment were more likely to be referred for discretionary indications than those in nongatekeeping plans (15.5% v 9.9%, P < 0.05). The frequency of referring physician coordination activities did not vary by health plan type. The proportion of patients in gatekeeping health plans within a practice was directly related to employing staff as referral coordinators, allowing nurses to refer without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages.


CONCLUSIONS
The specialty referral process for privately insured nonelderly patients enrolled in managed health plans is generally similar, regardless of the presence of gatekeeping arrangements and capitated PCP payment. An increase in the number of discretionary referrals among patients in plans with capitated PCP payment provides support for exploring strategies that encourage PCPs to manage in their entirety conditions that straddle the boundaries between primary and specialty care. In response to increasing numbers of patients enrolled in managed health plans with gatekeeping arrangements, physicians appear to modify the structure of their practices to facilitate access to and coordination of referrals.
Forrest
Christopher B
CB
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. cforrest@jhsph.edu
Nutting
Paul
P
Werner
James J
JJ
Starfield
Barbara
B
von Schrader
Sarah
S
Rohde
Charles
C
D002204:Capitation Fee; D003625:Data Collection / Q000379:methods; D005260:Female; D020793:Gatekeeping; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000191:economics*; D008875:Middle Aged; D009819:Office Visits / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000191:economics* / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000191:economics; D012017:Referral and Consultation / Q000191:economics* / Q000706:statistics & numerical data*; D014481:United States