Open access to specialists hasnt driven up costs and utilization, HMO executives say
HMO / Open Access
January 31, 1998
Managed care products offering consumers more direct access to specialty care so far have not produced substantial cost increases, say health plan executives. But, these "open-access" products require vigilant utilization monitoring and are best suited to mature markets where consumers and physicians are attuned to managed care, plan executives say.
"Our overall experience is, if you look at both costs and utilization, there’s very little difference between open access" and traditional gatekeeper products, said Sid Stolz, senior vice president of Minneapolis-based United HealthCare Corp., which began offering open access products in 1982.
But, "open access is not the program to begin the market," Mr. Stolz advises. "It’s really a delivery system evolution." Providers and consumers need to be comfortable with the workings of managed care for open access to succeed.
United offers open-access products in 26 states. More than half of the company’s 4.4 million HMO members are enrolled in open access plans.
Mr. Stolz said utilization hasn’t skyrocketed under the plans because consumers largely continue to use the system in the same way they did before. Nationally, 80% of United’s open-access enrollees still see their primary care doctors before consulting a specialist. "Our use of specialists is virtually the same," he noted. "People don’t just wake up in the morning and say, I’m going to go see a neurosurgeon.’"
Paul Markovich, director of product management and national accounts for Blue Shield of California, which began offering an open-access feature in September 1996, said that for many enrollees, open access is a security blanket. "There’s a real fear with consumers that they won’t be able to access the care that they need when they need it. This feature gives them the peace of mind that they can, but it doesn’t necessarily change the way they go about caring for themselves on a day-to-day basis."
Managed care plans experimenting with open access are not taking utilization for granted. Blue Shield, which allows members to directly access specialists within their medical group for a $30 copay, has a special unit that tracks claims for self-referred specialist visits and produces utilization reports for medical groups. Blue Shield created shared risk pools so that medical groups also would absorb unanticipated utilization increases, but so far none of the groups has exceeded projections, Mr. Markovich said. Since introducing the open access feature, he said, Blue Shield’s growth rate has doubled, member satisfaction has improved substantially and utilization "has been a fraction of what we expected."
Real-time monitoring
Mr. Stolz stresses that "real-time" monitoring of specialty utilization under open access is critical. "If you don’t have good data and open access gets out of control, it’ll be too late to correct it," he warns. "You have to know your specialty usage rates almost immediately." United HealthCare, he said, is moving to electronic data links with its contracting physicians in as many markets as possible.
United tries to design market-specific products that give consumers the choice they want and keep costs under control. Mr. Stolz said that plans carefully assess their markets, identify their top specialty cost drivers and then devise custom financial arrangements, which may include risk pools, discounted fee-for-service contracts or specialty-specific capitated rates. For example, in the Atlanta market, where Mr. Stolz said enrollment is "growing by leaps and bounds," United developed an extensive cardiology network by contracting with a large cardiology group, which is responsible for paying individual physicians. The plan is considering similar strategies for orthopedic services in Denver and otolaryngology in Boston.
Patient education and wellness programs also are important for successful open access products, said Jack Towsley, CEO of United HealthCare of Arizona, which has offered open access since September 1996. His plan has a 24-hour patient information phone service to answer members’ questions about health care needs and refer to resources in the community. "We try to use our information tools to better educate consumers and put them in a better position to make good health care decisions," Mr. Towsley said.
So far, he adds, the new product appears to be "at least as cost-effective" as the plan’s traditional gatekeeper product and has earned higher consumer satisfaction ratings. About 38,000 of the plan’s 48,000 members are enrolled in the open access product, Mr. Towsley said.
MDNY Healthcare, an IPA-model plan based in Melville, NY, is paying close attention to demographics as it monitors enrollment trends in its open access product. CEO Richard Radoccia said MDNY views its MDClassic plan as a higher-end product that will attract older, more educated members who are interested in taking a more active role in their care and don’t mind paying more for that flexibility. "We wanted to encourage people who are a little bit maturer to look at this as their plan of choice," Mr. Radoccia explains. Monthly premiums are about 20% higher for enrollees in that product than in the traditional gatekeeper model, he said.
"We’re pretty sure that it’s a more costly product, although we don’t have precise numbers yet," he said. "At the moment, it looks like our premium increment is covering the additional cost." Because MDNY is targeting an older population for MDClassic, Mr. Radoccia said he expects utilization to be higher. "The issue is whether it’s consistent by virtue of age and sex," he noted.
Catherine Hill, vice president of Scheur Management Group, a Boston-based consulting firm, said open-access products will require good information systems to track utilization and aggressive efforts to educate patients and physicians on cooperative and wise decision-making. "We are the beginning stages of figuring out how to implement open access," Ms. Hill noted. Until everybody has a little more experience with what works better, I think we’re going to see several permutations of this approach."
— Mary Darby
Contact Mr. Stolz at 612-204-8801, Mr. Markovich at 415-229-5814, Mr. Towsley at 602-200-1385, Mr. Radoccia at 516-454-1900 and Ms. Hill at 703-532-7010.
Open access to specialists hasnt driven up costs and utilization, HMO executives say
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