Health Care Costs and Financing

Capitated payments and gatekeeping practices have minor effects on referrals of managed care patients to specialists

The specialty referral process for privately insured patients enrolled in managed health plans is similar, regardless of the presence of gatekeeping arrangements (the primary care doctor has to authorize referrals to specialists) and capitated payments to the primary care physician (PCP), a capped amount per patient visit regardless of services performed. A new study found similar referral rates among managed care patients in gatekeeping plans with fee-for-service PCP payment or capitated PCP payment, even though the latter would appear to encourage referrals of complex, time-consuming patients. However, patients in plans with capitated PCP payment were more likely to be referred to specialists for chronic conditions and discretionary indications than those in non-gatekeeping plans, in which a patient can see a specialist without PCP referral (15.5 vs. 9.9 percent).

Physicians felt restricted in their ability to refer to the most appropriate specialists (due to restricted provider networks) in just 5 percent of cases. The proportion of patients in gatekeeping health plans within a practice was directly related to using staff as referral coordinators, allowing nurses to refer patients without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages.

Thus, physicians in managed care plans appear to modify the structure of their practices to facilitate access to and coordination of specialist referrals, according to Christopher Forrest, M.D., Ph.D., of the Johns Hopkins Bloomberg School of Public Health. For the study, which was supported by the Agency for Healthcare Research and Quality (HS09377), Dr. Forrest and his colleagues analyzed 14,709 visits made by privately insured, nonelderly patients seen by 139 PCPs in 80 primary care practices in 31 States. They examined the proportion of visits that resulted in a referral for specialty care, characteristics of referral, and physician coordination activities among gatekeeping plans with fee-for-service PCP payment, gatekeeping plans with capitated PCP payment, and non-gatekeeping plans.

More details are in "Managed health plan effects on the specialty referral process," by Dr. Forrest, Paul Nutting, M.D., M.S.P.H., James J. Werner, M.S., and others in the February 2003 Medical Care 41(2), pp. 242-253.

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