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


METHODS
We conducted a cross-sectional 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 worthwhile, 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.
Braun
Barbara L
BL
Health Research Center, Park Nicollet Institute, St. Louis Park, Minnesota 55416, USA. braunb@parknicollet.com
Fowles
Jinnet Briggs
JB
Forrest
Christopher B
CB
Kind
Elizabeth A
EA
Foldes
Steven S
SS
Weiner
Jonathan P
JP
D000328:Adult; D003258:Consumer Behavior; D003625:Data Collection; D004522:Educational Status; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D020403:Patient Freedom of Choice Laws / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000458:organization & administration / Q000706:statistics & numerical data*