Self-referral in Point-of-Service Health Plans

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Abstract
Perceived barriers to obtaining specialty care are one of the greatest sources of consumer dissatisfaction with today's health maintenance organizations (HMOs).1 Primary care physicians report difficulties obtaining specialty referrals in health plans with "gatekeeping" arrangements2 and capitated payment.3 In response to these consumer and practitioner concerns, most HMOs now offer products, such as the point-of-service (POS) plan, with loosened restrictions on patients' access to specialty care. The triple-option POS plan is a blend of an HMO, preferred provider organization, and indemnity plan. Point-of-service members who use the principal HMO network and obtain authorization for referral services from their physician "gatekeeper" have minimal levels of cost sharing. Patient self-referral within the plan's network of practitioners is associated with moderate patient cost sharing, whereas self-referral to out-of-network practitioners has out-of-pocket payments comparable with indemnity plans.