Responding to consumer complaints about the HMO "gatekeeper" system, Blue Shield of California is hoping to set itself apart from the pack by allowing HMO enrollees direct access to specialists.
That's another sign HMOs are continuing to modify their product offerings to meet consumers' demand for greater choice and flexibility. Generally, HMO enrollees must get a referral from their primary-care physician to see a specialist.
Many HMOs have introduced point-of-service plans, which allow enrollees to visit non-network providers by paying a deductible and coinsurance.
Blue Shield's "Access+ HMO" takes another tack. Beginning in September its 325,000 enrollees will be able to seek treatment from a specialist within their medical group without a referral from their primary-care physician, for a simple copayment of $30. The standard copayment is $5 to $10. If they are dissatisfied with their choice, they may request a refund of the copayment.
Blue Shield said it's allowing direct access to specialists in response to a consumer survey it commissioned, showing that 40% of HMO enrollees had concerns or complaints about access to specialists.
Direct access to specialists is not a new idea. For example, Kaiser Permanente plans allow members direct access to certain specialists. Since 1982, United HealthCare Corp. has offered a plan that allows members to see specialists without a referral from their primary-care physician.