Are Gatekeepers Failing To Control Specialty Costs?

The importance of a gatekeeper in keeping costs down has been challenged again — this time in a study that compares physician utilization for HMOs and point-of-service plans. The study, sponsored by the U.S. Agency for Healthcare Research and Quality, found no evidence that HMOs that use primary care physicians as gatekeepers keep specialty costs lower than POS plans that do not use the gatekeeper.

The researchers examined claims from 1994 and 1995 for visits of 50,000 privately insured working-age patients enrolled in two plans operated by a Midwestern company.

HMO members received routine care and referrals to specialists from the 1,152 generalists in a physician network shared by both plans. The POS plan provided generous coverage for self-referral to the 1,692 specialists in the network.

When the researchers examined claims for patients with no copayment requirement for either primary care or referred visits to specialists, they found that the overall cost of physician services was 4 percent higher in the gatekeeper HMO than in the POS plan.

When copayments were $10, physician expenditures varied from being roughly equal for both plans to being 7 percent higher in the gatekeeper HMO.