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August 8, 2001

Factors Affecting Patients' Self-referral to Specialists

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorJody W.ZylkeMD, Contributing EditorIndividualAuthor

JAMA. 2001;286(6):672-673. doi:10.1001/jama.286.6.672

To the Editor: In their study of the patterns of self-referral by patients in point-of-service (POS) health plans, Dr Forrest and colleagues1 noted that the number of out-of-plan self-referrals was extremely low—between 0.2% and 1.8% of enrollees. In the 2 Blue Cross/Blue Shield plans that they examined, this likely reflected market conditions in which nearly all physicians in the geographic area were enrolled in the plans, but the rate was also quite low in the plan with the smaller network. From either an economic or a care coordination perspective, health plans may be relatively indifferent to the self-referrals to within-plan providers. Most of the theoretical value of POS plans to consumers and most of the potential costs of POS plans to insurers apply to out-of-plan referrals. While the limited number of out-of-plan visits may prevent further analyses in this dataset, future studies on the patient and market predictors of out-of-plan resource use would be extremely valuable in understanding the benefits and costs associated with POS health plans.

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