Health Care Choice That's Cost-Effective

When it comes to health care, Americans like to have choices, and now a study led by health policy experts at the School shows that greater choice can be cost-effective as well. In a study led by Christopher Forrest, associate professor of Health Policy and Management, researchers found that plans that allow patients to see a specialist without a referral are affordable for health maintenance organizations (HMOs) because patients rarely use the option and are willing to pay more to have it. The results of this study, says Forrest, MD, PhD '95, should encourage HMOs to offer more choices to their patients and may provide valuable insight for policy makers reforming Medicare.

An HMO patient is often placed under the care of a primary care physician, or "gatekeeper," who decides whether or not the patient should see a specialist. Problems can arise when patient and doctor disagree about whether such referrals are necessary. So, many HMOs have begun providing so-called "point-of-service" (POS) plans, which for an additional fee allow a patient to see a specialist without a referral. POS plans have been gaining popularity among patients ever since the early 1990s, but HMOs have wondered and worried, says Forrest, "Is it going to break the bank?" 

The conclusion: Patients don't seem to be making a lot of unnecessary visits, according to the study by Forrest and his colleagues that appeared in the May 2, 2001, issue of the Journal of the American Medical Association. The study, which reviewed data from roughly 386,000 patients enrolled in POS plans nationwide, showed that only 4 to 7 percent of patients referred themselves to specialists without consulting their primary care physician. A follow-up phone survey of 600 patients who went to a specialist on their own showed that most did so because they wanted immediate access to specialty care or because they didn't get along with their primary care doctor. Why don't patients self-refer more often? Forrest believes it's because most patients have good relationships with their primary care physicians and are likely to seek their advice before seeing a specialist. Nonetheless, he adds, patients like to have the peace of mind of knowing they can see a specialist any time they want to.

"There has been a relative dearth of research on point-of-service plans," says Steven Foldes, a senior researcher for Blue Cross Blue Shield of Minnesota. Foldes believes that Forrest's "impressive study" is an important first step in gauging the impact that POS plans will have on the health care industry. 

Says Forrest, "I think that this study provides evidence that [a POS plan] may be a viable alternative for Medicare."