Self-referral in point-of-service health plans

JAMA. 2001 May 2;285(17):2223-31. doi: 10.1001/jama.285.17.2223.


Context: Most health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan.

Objectives: To comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care.

Design: Retrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan.

Main outcome measures: Self-referred service use and charges, reasons for self-referral, and satisfaction with specialty care.

Results: Overall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received.

Conclusions: Having the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Algorithms
  • Child
  • Child, Preschool
  • Economics, Medical
  • Fee Schedules
  • Female
  • Health Care Surveys
  • Health Maintenance Organizations / economics
  • Health Maintenance Organizations / organization & administration*
  • Health Services Accessibility / organization & administration*
  • Humans
  • Infant
  • Male
  • Medicine / standards
  • Middle Aged
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Patient Satisfaction / statistics & numerical data
  • Referral and Consultation / economics
  • Referral and Consultation / statistics & numerical data*
  • Retrospective Studies
  • Specialization
  • United States