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.
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.
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.
Main Outcome Measures
Self-referred service use and charges, reasons for self-referral, and
satisfaction with specialty care.
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
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.