Plans setting higher specialist co-pays

Health plans are instituting tiered payments to put a lid on rising premiums. But doctors say they restrict access to care and imply some physicians are second-rate.

By Myrle Croasdale, AMNews staff. April 1, 2002.

Managed Care: What's Next?"
With the managed care system drawing complaints from all quarters, doctors, patients, payers and even insurers themselves found themselves looking for alternatives to a concept that hadn't met its promise of improving care while reducing costs. This 2000-02 occasional series highlighted what physicians and others were doing to come up with a way to improve the system -- or replace it with something else.

Thanks to a new concept called tiered co-pays, Newton, Mass., internist John La Rossa, MD, thinks he might have to talk to patients about money as much as medicine when it's time to refer them to a specialist.

Patients enrolled in Tufts Health Plan might pay $10 to be treated by him, for example, but if they go to a specialist, it could cost $35. The plan is replacing equal co-pays for all doctors with tiered co-pays in an effort to keep a lid on fast-rising premiums.

According to a letter Dr. La Rossa said he received from Tufts, "They were trying to pressure patients to not go to specialists, to stay with their primary doctor. As an incentive to get patients to not see a specialist, they'll charge them more money."

Tufts isn't the only plan to adopt tiered co-pays, nor are specialists the only target.

In California, PacifiCare and Blue Shield of California are actively marketing tiered hospital co-pay products. Blue Cross Blue Shield of Massachusetts is marketing a tiered plan aimed at employers looking to pare premiums. UnitedHealthcare, Blue Cross and Blue Shield of Florida, CIGNA and Humana all have products in the works.

Health insurers say they are creating such products because employers are begging for relief from double-digit increases in premiums.

Catherine Grant, spokeswoman for Tufts Health Plan, Waltham, Mass., said, "The reason we're doing this is that we know employers are confronting tough decisions on affordability. An increase in premiums can mean the difference between continuing to offer coverage or dropping coverage altogether." [...]