A lack of understanding about procedures may impede referrals to specialists as much as health plan bureaucracies do, according to a membership survey of the California Public Employees Retirement System.
"Physicians themselves don't always understand precisely how the referral process works . . . , (and) many patients don't know how to gain access to a specialist, don't always know when it's appropriate and don't know how to appeal if they have trouble getting a referral," said a written statement issued Aug. 18 by CalPERS, one of the nation's largest purchasing pools.
CalPERS provides benefits to more than 1 million current and retired public employees in California and their dependents.
The results came from a survey of 500 CalPERS members enrolled in the Woodland Hills-based Health Net HMO and four medical groups that provide their care. The survey is part of a project designed to improve access to care without driving up costs. The project is co-sponsored by CalPERS, Health Net, a research firm called California Health Decisions and the four medical groups.
While CalPERS expressed surprise at the problem, it also acknowledged that a crisis level of concern has yet to be reached: Two-thirds of those surveyed expressed satisfaction with the way they have received referrals. And although specifics of the survey will not be published until late September, CalPERS spokesman Bill Branch indicated that simple misunderstandings seem to be exacerbating the situation.
He noted that physician confusion about referrals may be because of the customary practice in California of belonging to several HMO panels. "The doctor is dealing with a number of HMOs and a number of specific processes, and there may be mix-ups," he said.
CalPERS officials also observed that patients are often frustrated by expecting quick treatment by a specialist who "may be booked up for weeks in advance."
Branch said his agency would look into educational solutions. Among other efforts, "CalPERS will probably review and clarify their coverage booklets," he said.