Managed care easing gatekeeper hassles

Thanks to physician and patient pressure -- and the realization it wasn't saving money -- some plans stop requiring patients to get referrals before seeing specialists.

By Robert Kazel, AMNews staff. Jan. 20, 2003.

For several years, Harold Brown, MD, a family physician in Beavercreek, Ohio, has spent more than $35,000 annually on staff just to take care of patients whose health plans require a primary care referral in order to see a specialist.

"Referrals have been a wall we had to jump over before we could provide necessary care," Dr. Brown said. "We have to push papers and wait on the phone for up to a half-hour with some HMOs for something that was going to be authorized anyway."

As it turns out, some HMOs are thinking the same thing as Dr. Brown. Deciding it's not worth ticking off physicians and patients for a system that's not saving any money, some health plans are dropping the so-called gatekeeper model that has been a bulwark of managed care.

For example, Anthem Blue Cross and Blue Shield as of Jan. 1 eliminated most referral requirements for its HMO patients in Indiana, Kentucky and Ohio. The change, which affects some 400,000 Anthem members, swept away gatekeeping regulations for all except Medicare HMO patients and care received through a mental health carve-out plan.

The change in rules resulted from "customer pushback" -- plan-speak for increasing complaints from patients -- as well as doctor opposition, said Mark Isett, vice president of product development for the company's Midwest region.

"If anything, it's going to reduce administrative hassles and costs for physicians," he said. "Particularly with physicians, we decided, what's the advantage to continue to market a product with gatekeeping?" Eliminating referrals will probably also produce "a small but significant administrative savings for Anthem," he said.