The gatekeeper concept is ailing, and experts consulting on the case say it may never be the same again.
Responding to demands of providers, patients and employers, some managed-care companies are augmenting their gatekeeper provisions to allow easier access to specialists. It is a trend that is expected to continue.
"The customers have spoken clearly, and free access is what they want," says Bob Smoler, chief executive officer of Oxford Health Plans' New York region. Oxford is based in Norwalk, Conn.
Like many of its competitors--including Humana, United HealthCare Corp. and Blue Shield of California--Oxford now offers a product allowing enrollees to refer themselves to specialists without going through gatekeepers.
"Open-access plans respond very well to the concerns of consumers about limitations on access to specialists," says Russell C. Coile Jr., senior vice president at Chi Systems in Ann Arbor, Mich., and former owner of the Health Forecasting Group in Plano, Texas. "Consumers like the concept of having a personal physician, but they don't want that person to also be a traffic cop or bureaucrat. So here's a way for HMOs to maintain the traditional model with a gatekeeper and still give customers access to specialists without going through a gatekeeper."
Coile says consumers usually pay a "toll charge"--a higher copayment (around $15 to $20) or an increased premium--to self-refer to specialists. Some managed-care companies have also restructured their provider fee schedules to compensate for the change.
Despite the higher prices, Coile believes open access is here to stay. "Most markets have a competitive number of HMOs where plans compete on price," he says. "If there's not much difference in price, then the enrollees look at convenience, access, service and choice."
While consumers and most specialists are happy with open access, primary-care physicians are concerned about their role in "the managed-care food chain," Coile says. "But," he says, "I think it's a healthy evolution of managed care."
Oxford anticipated the reaction of primary-care physicians and took steps to ensure their visibility and utilization. For starters, the company instituted an enrollee education program that emphasizes when to visit a primary-care physician and when to see a specialist. Every time an enrollee visits a specialist directly, Oxford sends information about that interaction to the enrollee's primary-care physician so he or she can "stay in the loop and maintain the position of quarterback," Smoler says.
"Primary-care physicians are concerned that members might be accessing the healthcare system without knowing what's going on in their treatment," he says. "We want to show that Oxford is taking a stand for them, so they'll feel good that they lost the administrative burden (inherent in the gatekeeper system)."
At least one doctor thinks that approach makes sense. "As a physician, you like the fact that you eliminate those patient visits where a patient is initially coming to you but going right on to see a specialist," says Charles D. Kennedy, who practices one day a week as an internist for Kaiser Permanente and also serves as director of informatics for Blue Shield of California. "It's inefficient and not very rewarding in terms of your practice."
Louisville, Ky.-based Humana is another company that has latched onto the open-access concept. Michael Brouthers, executive director of Humana Northeastern Florida, says the company realized that the marketing appeal of a traditional, tightly controlled gatekeeper HMO was reaching its peak. "We weren't losing membership, but we were finding it harder to find more converts," he says. Facing escalating pressure from enrollees, and concerned about possible legislation, Humana designed HumanaFreedom and HumanaFreedom Plus to give enrollees more direct access to specialists.
"It was our belief that we should look for a model that deals with all the objections people have before we were legislated to do it," he says.
Brouthers says he made sure he discussed the changes with the physicians in his area before going forward.
"Almost without exception, primary-care physicians are very excited that they will still be treated by the health plan as the key coordinators of care," Brouthers says. "We strongly encourage members to use primary-care physicians and educate them on the value of a 'medical home.' And primary-care physicians are glad they're no longer set up into a combative relationship with patients who go to them only when they want a referral (to a specialist). This takes them out of a controversial issue."
Brouthers expects primary-care physicians to focus more on preventive care now, which he emphasizes "was the original intent of the HMO movement." But he admits that some primary-care physicians are concerned their patient volume will drop or they will make less money now that their compensation isn't tied to a utilization bonus program.
"I tell physicians that if they've treated people nicely and taken good care of them, they have nothing to worry about," Brouthers says.
While primary-care physicians are worried about declining volume, specialists fear open access will open the floodgates. Yet Blue Shield of California, which initiated its open-access plan last September, didn't see that effect. "We have seen limited utilization of the specialists," explains Ken Prewitt-Wood, senior vice president of marketing for Blue Shield. "Open access is predominantly a psychological benefit, an empowerment of consumers to involve them in their healthcare and let them know they have a say. It's not some pent-up demand to see specialists."
Kim Klancke, M.D., a cardiologist in private practice in Daytona Beach, Fla., who is affiliated with Humana, says he has only limited concern about increases in the volume of patients. "It may be less work if we can keep these people stable and out of trouble. It's easier to do that than to bail them out when they're having problems."
Prewitt-Wood, referring to speculation that open access would increase costs and confusion, says there is "absolutely no evidence this has happened. People are [self-referring] in a responsible way."
Kennedy says additional costs have been less than $1.70 per enrollee per month. "And that low cost is certainly worth it compared to the growth we've experienced," he says.
Before Blue Shield of California launched its open-access program, the company met with eight to 10 of the largest medical groups in its network to discuss the changes. Prewitt-Wood says 80% of the groups and independent practice associations agreed to participate in open access, and those who did saw an average enrollment increase of 40% during the first nine months. Comparatively, the providers that didn't participate experienced less than 5% growth. Blue Shield also saw a 30% decline in the number of complaints involving access to specialists.
Kennedy sees open access as being positive for both patients and physicians. "Patient satisfaction has gone up tremendously, especially with regard to grievances, because access to specialists is one of the main grievances people make."
Sid Stolz, senior vice president of product and network development for Minneapolis-based United HealthCare, says open-access plans save time and money for both providers and healthcare organizations.
"It's a huge advantage to primary-care physicians," he says, "because they spend less time doing referrals and have more office time for other types of visits." And when physicians don't need to check with the managed-care organization regarding referral information, the companies can allocate their personnel to other areas. "We've moved those resources into other services, such as monitoring use of hospitals and specific diseases, rather than tracking who's referring who to whom," Stolz says. "It took a lot of bodies to take calls and track referrals, and most were approved anyway."
Stolz says now the company is focusing on high-cost cases, catastrophic cases and "diseases where we know we can have an impact, such as diabetes, congestive heart failure and asthma, where we can prove that if we can get people in these (disease management) programs we can provide better care and manage costs."
Stolz says United HealthCare "still believes there needs to be a gateway," but the lead healthcare worker may be a primary-care physician, a specialist or even a nurse.
As managed care continues to evolve and open access becomes more prevalent, managed-care companies, providers and employers need to listen more to consumers and respond to their needs, Prewitt-Wood says. And providers are key.
"So many physician executives are working with how to bring groups together and grow from a business perspective," he says. "This is a place where taking calculated risks makes sense. The American population at this point is not completely satisfied with the managed-care system, and physicians are at the heart of making that better."
Robin F. DeMattia is a freelance editor and writer based in Connecticut.