Forrest CB, Weiner JP, Fowles J, Vogeli C, Frick KD, Lemke KW, Starfield B. Self-referral in Point-of-Service Health Plans. JAMA. 2001;285(17):2223-2231. doi:10.1001/jama.285.17.2223
Author Affiliations: Health Services Research and Development Center, Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Md (Drs Forrest, Weiner, Frick, Lemke, and Starfield and Ms Vogeli); and Health Research Center, Park Nicollet Institute, Minneapolis, Minn (Dr Fowles).
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
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.
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.
From 1993 to 2000, US employer-based enrollment in POS health plans
increased from 5% to 22% of those covered, one of the fastest growth rates
among any type of managed care plan.4 By 2000,
44% of workers had a choice of a POS health plan,4
and in 1999, more than three quarters of HMOs offered a POS option.5 One reason for this growth is the hybrid nature of
POS plans, which can facilitate an individual's transition from indemnity
insurance to managed care.6 Patients may view
POS plans favorably, because they maintain practitioner choice while offering
lower premium costs than traditional insurance. Despite these perceived benefits,
POS plans may have greater actuarial uncertainty due to out-of-network utilization,
potentially poorer coordination of care, and higher administrative costs associated
with claims processing.7
The limited information available suggests that POS health plan members
infrequently exercise their option to self-refer. Using 1990-1991 data from
1 POS health plan, Wong and Smithen8 reported
that 12% of claims accounting for 9% of expenditures were due to out-of-network
utilization. In an analysis of 1994-1995 data from another POS health plan,
Kapur et al9 found that 7% of expenditures
were due to patient self-referral.
The growing importance of POS and other direct-access managed care models
calls for more comprehensive evaluations to better understand this new type
of managed health plan. Some basic questions about POS plans remain unanswered:
Which patients are most likely to opt for self-referral when seeking specialty
care? Why do patients bypass their primary care physicians? What is the impact
of self-referral on patient outcomes? Using data from 3 commercial insurers
in separate markets, this study addresses these questions and provides a detailed
assessment of the self-referral process within POS health plans. Our aims
were to quantify self-referred service use and charges, to identify patients
most likely to obtain specialty care via self-referral, to characterize patients'
reasons for self-referral, and to test the association between self-referral
and satisfaction with specialty care.
Administrative databases from 3 commercial POS health plans were the
primary data sources. The study period was calendar year 1996. All 3 were
triple-option POS health plans, which gave members 3 alternatives at the "point
of service": option 1, service use approved by the primary care physician
involving the lowest level of cost sharing; option 2, self-referral within
the provider network with an intermediate level of cost sharing; and option
3, self-referral to an out-of-network practitioner involving the highest level
of cost sharing. For example, a member in a typical POS plan in this study
had option 1 services of a $10 co-payment, no deductible, and no coinsurance;
option 2 services of a $20 co-payment, a $0 to $100 deductible, and 20% coinsurance;
and option 3 services of a $200 to $1000 deductible and 20% coinsurance.
Two of the POS plans were insurance products offered by not-for-profit
BlueCross/BlueShield insurers in the Midwest and Northeast. Both had provider
networks composed of most physicians and hospitals in the states they served.
The third plan was a for-profit mid-Atlantic insurer that contracted with
a more limited subset of practitioners in the state it served.
The study sample was composed of individuals aged 0 to 64 years enrolled
for 6 to 12 months in 1996. We excluded mental health practitioner, substance
abuse, and outpatient pharmaceutical claims because these services were separate
"carved out" benefits that were administered by other organziations and not
included in the administrative database. The claims systems of each plan permitted
us to include all claims in the analysis, regardless of whether the member's
deductible (if applicable) had been met.
Plan membership files were used to assign age and sex, calculate months
of enrollment, determine if enrollees were new to the plan, and categorize
members by their policy's level of office visit co-payment and deductible,
if any, for option 1 (gatekeeper-approved) services. The ZIP codes of enrollees'
residences were linked to the US Department of Health and Human Services Area
Resource File to determine urban/rural residence.10International Classification of Diseases, 9th Revision, Clinical
Modification (ICD-9-CM) diagnosis codes were
matched to a set of 182 diagnosis clusters, which our research team expanded
and modified from the original set of 92 by Schneeweiss et al.11
A subset of clusters was categorized as chronic medical conditions using the
criterion of expected continuous duration of 12 months or more.
Patient comorbidity was assessed using the Johns Hopkins Adjusted Clinical
Group (ACG) Case-Mix Assessment System.12 The
first step in the ACG assignment process is to link ICD-9-CM diagnosis codes to 1 of 32 aggregated diagnostic groups (ADGs). Each
ADG is a morbidity grouping with clinically homogeneous diagnosis codes that
have similar expected need for health care resources. We used ADGs in this
study for case-mix assessment. Diagnosis codes from health care claims in
all care settings—except laboratory and radiology facilities, which
submit a high proportion of claims for rule-out diagnoses—were used
to assign ADGs.
The majority of physicians were assigned to a specialty group according
to the self-reported specialties recorded in the American Medical Association
Masterfile (82%-84% of all physicians across the 3 plans). The Masterfile
was also used to determine years in practice. Specialty information for physicians
whom we could not match to an entry in the Masterfile and nonphysician clinicians
was obtained from the plans' files. Across the 3 plans, specialty information
was missing for 0% to 1.3% of physicians.
Generalists included physicians whose only specialty designation was
family medicine, general practice, pediatrics, internal medicine, or obstetrics/gynecology.
We included gynecologists in the generalist category because health plans
allowed women to select both a family physician or internist and an obstetrician/gynecologist
as their primary care physicians. In the mid-Atlantic and northeastern plans,
obstetricians/gynecologists had "gatekeeping" authority; in the midwestern
plan, they did not. Individuals with both generalist and specialist designations
were classified as specialists.
We assigned patients to a single "regular" physician for analyses that
examined patient and regular physician characteristics (eg, specialty of the
regular physician, years in practice) associated with self-referral to specialists.
The method was based on patients' actual patterns of service use and selected
the primary care physician seen most frequently. As an alternative to this
utilization approach, we could have used health plan records to identify a
patient's regular physician; however, 1 of the plans required patients to
select a primary care group rather than a specific clinician. Thus, a utilization-based
approach provided a common method for selecting a regular physician across
the 3 plans.
Specifically, the method assigned a patient to the generalist physician
with whom the patient had the largest number of visits. Self-referred visits
were excluded from these assessments. Patients who made an equal number of
visits to 2 or more generalists were assigned the 1 who provided the most
resource-intensive services as measured by charges. Assignment to a specialist
was permitted for individuals with no visits to a generalist. Using this method,
we assigned between 90% and 93% of patients with some ambulatory care use
at each POS plan to a regular physician. The 7% to 10% of unassigned patients
either had no physician visits or the method was unable to resolve ties.
To assess the strength of the physician-patient relationship, continuity
of care was calculated as the percentage of physician visits made to the regular
To remove the differences in fee schedules within and between plans,
we standardized charges to a common set of values. Current
Procedural Terminology codes were priced using the 1997 Medicare resource-based
relative value scale. Relative values were converted to dollars using a conversion
factor of $35 per unit. For other procedure codes, mean charges from the largest
health plan were used as the standard rate. Using the principal diagnosis,
inpatient stays were assigned to a Major Diagnostic Category (MDC) of the
DRG system.15 Mean per diem rates for each
MDC were calculated for children and adults separately in 1 health plan. To
obtain standardized inpatient expenditures for a hospitalization, these MDC-specific
per diem rates were multiplied by the length of stay in days.
For each patient, ambulatory charges were obtained by summing the standardized
charges for each service occurring in an ambulatory setting. Inpatient charges
were the sum of the standardized charges for all hospitalizations, including
both institutional and physician charges. Total charges were the sum of ambulatory
and inpatient charges.
Ambulatory charges were disaggregated into 8 categories: generalist
visits, specialist visits, nonphysician clinician services, surgery, diagnostic/therapeutic
procedures, laboratory, radiology, and other. These groupings were based on
the method developed by Berenson and Holohan16
and assigned Current Procedural Terminology codes,17 level II codes in the Common Procedure Coding System,18 and revenue center codes to 1 of the 8 clinical service
categories. Outpatient physician visits were divided into generalist and specialist
categories according to the specialty of the billing physician.
Claims for physician, institutional, and ancillary services in each
data set were designated as regular physician–approved (option 1) or
self-referred within or outside of the provider network (options 2 and 3,
respectively). The mid-Atlantic and northeastern plans had additional designations
that allowed separation of self-referral within and outside of the provider
The survey protocol was approved by the Johns Hopkins School of Public
Health Committee on Human Research. We conducted a telephone survey of patients
in the midwestern POS health plan who had recently seen a specialist. The
sample was selected using claims data and included members aged 0 to 64 years
(parents responded for 0- to 17-year-old patients) who had a visit to a medical
or surgical specialist 2 to 6 months before survey administration. Members
with insurance coverage by more than 1 plan were excluded. The response rate
The survey instrument contained items that separated patients based
on their most recent specialist visit into those who self-referred vs those
referred by their primary care physician. Patients who self-referred were
asked, "Why did you choose not to have your primary care doctor authorize
your referral to the specialist?" Interviewers recorded verbatim the single
main reason for self-referral. The telephone survey also queried both physician-referred
and self-referred patients about their satisfaction with the specialists in
the health plan and their satisfaction with their most recent specialist visit.
We calculated rates of specialty self-referral as the annual percentage
of health plan members who exercised their option to self-refer for a specialist
visit overall, for out-of-network practitioners, and by physician and nonphysician
clinician specialty categories. For inpatient and ambulatory services, average
annual standardized charges and the percentage self-referred were calculated.
The denominator for these analyses was all enrollees in the plan. Replication
of findings using each health plan's actual "allowed" charges did not substantively
alter parameter estimates or conclusions. We excluded chiropractic and eye
care services from analyses related to self-referral in POS health plans because
each plan allowed limited self-referral to these specialties as an option
Multivariable linear regression that controlled for patient characteristics,
case-mix, and months of enrollment was used to obtain adjusted mean charges.
Thus, charges are presented as standardized dollars, adjusted for population
We used logistic regression to identify characteristics of patients
and their regular physicians associated with obtaining specialty care via
self-referral. The sample was restricted to patients with at least 1 medical
or surgical specialist visit in 1996. A visit was defined as an encounter
that involved provision of an evaluation and management service. We excluded
a specialist acting as a patient's regular physician from the pool of physicians
to whom the patient could possibly self-refer. Separate regression analyses
were performed for each plan. The generalized estimating equation was used
to account for the correlation among patients assigned to the same regular
Table 1 presents characteristics
of enrollees at each of the 3 study sites. Age and duration of enrollment
selection criteria excluded 17.5% to 25.4% of all members. The northeastern
POS plan was growing rapidly, with 33.2% of members newly enrolling in 1996.
Virtually all enrollees in the mid-Atlantic POS health plan resided in urban
areas. Compared with members in the midwestern plan, those in the mid-Atlantic
plan were 2.2 times more likely to have 2 or more chronic conditions.
Rates of self-referral by practitioner specialty are presented in Table 2. 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. Orthopedic surgeons and dermatologists were the 2 most
common types of specialists to whom enrollees in each plan self-referred.
Data from 2 of the plans permitted an analysis of whether self-referral
was within or outside of the plans' provider networks. Just 0.2% of enrollees
in the northeastern POS plan and 1.8% of enrollees in the mid-Atlantic POS
plan self-referred to a specialist outside of the plan's network.
Table 3 presents mean annual
standardized charges per enrollee and the percentages of each service obtained
via self-referral. The proportions of total charges due to self-referral were
remarkably similar between the northeastern and mid-Atlantic POS plans (16.3%
and 15.7%, respectively). Across the 3 plans, self-referred charges as a percentage
of the service category tended to be highest for nonphysician services, specialist
visits, and invasive diagnostic and therapeutic procedures (eg, endoscopic
and oncologic services), and tended to be lowest for generalist visits and
Among patients with at least 1 visit to a specialist, 16.6% in the Midwestern,
29.8% in the northeastern, and 24.5% in the mid-Atlantic self-referred for
1 or more of their specialist visits. Table
4 presents results from logistic regression analyses that examined
the effects of patient and regular physician characteristics on the odds of
making a self-referred specialist visit among users of specialty care. Individuals
with unstable chronic conditions, allergies, orthopedic problems, and injuries
had increased chances of a self-referral compared with their counterparts.
Having no or small co-payments for option 1 services (regular physician–authorized)
decreased the odds of self-referral by 12% to 21% compared with persons who
had higher levels of cost sharing.
Higher levels of continuity with the regular physician were associated
with decreasing odds of self-referral in an exposure-response type of relationship.
This relationship held true in a sensitivity analysis that selected patients
with only 1 specialist visit.
In a telephone survey conducted in the midwestern plan, we asked the
patients who recently self-referred why they chose to bypass their primary
care physicians. Most commonly, patients (37.5%) reported that they preferred
to directly access a specialist to save time or to choose their own specialist.
The second most common reason (27.8%) was that patients experienced relationship
problems with their primary care physicians. Such problems most commonly occurred
because physicians refused to make a requested referral. Some patients (22.9%)
responded that an established relationship with a particular specialist was
the reason for self-referral. A small number of patients (8.3%) were confused
about insurance rules and did not realize they needed physician authorization.
Just 3.5% of patients self-referred because they did not have a primary care
Among respondents to the telephone survey, we compared satisfaction
with specialists available in the plan and satisfaction with their last specialist
visit between patients who obtained physician-approved referrals and those
who self-referred. Results are shown in Table 5. Members who self-referred were more likely to be satisfied
with their specialist visit and less likely to be satisfied with the health
plan's specialist network.
This study provides a comprehensive assessment of the self-referral
process within the POS health plan type. Our results show that in 3 geographically
distinct markets, a minority of POS members exercised their option to self-refer;
just 4% to 7% of members self-referred for a specialist visit. In 2000, employers
and their workers paid an average of $623 per year more for a family POS health
plan premium than a traditional HMO.4 This
sum is the price consumers and benefit managers acting on their behalf appear
willing to pay to maintain the possibility of direct access to specialists,
even though patients infrequently use this option.
Surprisingly, the proportion of enrollees who self-referred to specialists
was about the same as the proportion who self-referred to generalists. Point-of-service
members may use their self-referral options to maintain or expand relationships
with primary care physicians who do not participate in the plan or to develop
new relationships. In a 1991 survey of individuals who recently switched into
a POS plan, 36% reported retaining their primary care physician.20
Although this study is the largest and most comprehensive analysis on
POS plans to date, characteristics of the study populations influence the
generalizability of findings. First, all individuals in this study had privately
financed health care and were younger than 65 years. Although POS plans are
still uncommon in government programs, our findings might not apply if Medicare
or Medicaid implemented such a benefit structure more widely. Second, study
sites were located in 3 health care markets with relatively high managed care
penetration. A community where patients have less experience with "gatekeeping"
arrangements could have higher rates of self-referral than those found in
this study, possibly because a larger proportion of members would use the
POS plan as if it were a standard indemnity plan. Third, 2 of the 3 insurers
in our study were BlueCross/BlueShield plans, with very high provider network
participation within the states they served. Point-of-service plans with less
provider participation may have experiences that more closely resemble those
of the mid-Atlantic plan in our study, which had higher rates of out-of-network
utilization than the northeastern plan. Last, we excluded services provided
by optometrists, ophthalmologists, and chiropractors from the self-referral
analyses because plans allowed limited direct access at no added cost to these
specialties. We also excluded services provided by mental health practitioners
because, as is frequently the case among managed care health plans, these
services were administered by separate organizations. In another study performed
in 1 POS health plan, mental health services were the most common type of
out-of-network care obtained.8
Another limitation to consider is the accuracy of administrative data
for measuring self-referred utilization and practitioner specialty. In each
of the 3 claims databases, a single variable defined the benefit level of
the service, ie, option 1 (physician-approved within network), option 2 (self-referred
within network), or option 3 (self-referred out of network). This variable
was linked to payment, which may enhance its validity.21
This study relied primarily on specialty designation reported to the
American Medical Association. Although self-designated specialty information
may lead to some misclassification compared with board eligibility and certification,
we elected to use the former, which characterizes how physicians present themselves
in their communities.
Regression analyses of the patient and physician factors associated
with self-referral to specialty care used a utilization-based algorithm to
impute the regular physician. Northeastern and mid-Atlantic plan enrollees
who had both an imputed regular physician and a plan-assigned physician gatekeeper
were included in a sensitivity analysis. Findings revealed no substantive
differences in the effect sizes from the logistic regression analyses nor
were conclusions altered by using the imputed regular physician rather than
The rate at which enrollees exercised their POS options for self-referral
was markedly lower in the midwestern plan compared with the other 2 plans.
In the former, gatekeeping authority resided with physician groups, many of
which were organized as multispecialty practices. Utilization within the physician
group was not associated with increased costs to the patient, ie, it was considered
an option 1 service. Thus, some self-referral in the midwestern plan probably
occurred within the large multispeciality group practices. Because these self-referrals
were not captured in our database, we may have underestimated the rates for
the midwestern plan. A second explanation for the lower self-referral rates
in the midwestern plan is that it was located in a state with the highest
managed care penetration among the three plans. Midwestern plan members may
have been more accustomed to a managed care environment and restricted access
to specialists. Indeed, annual rates of specialist use were lowest for midwestern
POS plan members.
Charges due to self-referral in the northeastern and mid-Atlantic plans
were remarkably similar overall and by type of service. About 16% of total
charges and 20% of specialist visit charges were due to self-referred services
in both plans. Furthermore, 7.2% of enrollees in both plans self-referred
to specialists. These similarities are striking considering the plans' different
geographic markets, tax status, type of ownership, provider network, and patient
populations. On the other hand, out-of-network specialist self-referral rates
were lower in the northeastern plan (2/1000 members per year) compared with
the mid-Atlantic plan (18/1000 members per year). This disparity can be explained
by the northeastern plan's large BlueCross BlueShield provider network in
which virtually all physicians in the service area participated. Despite this
higher rate of out-of-network use in the mid-Atlantic plan, its overall standardized
ambulatory charges were lower than the northeastern plan, suggesting that
a smaller provider network is not likely to lead to excessive costs due to
self-referral. However, standardizing charges removes differences in fees
set by out-of-network practitioners, who almost certainly will bill at higher
rates than in-network physicians.
Compared with the plans in our study, Wong and Smithen8
reported a higher rate of out-of-network users (16% of members per year) in
their study of a single POS plan using data from 1991. The patient sample
in that study was substantially older than the sample for which we report
results (mean age, 48 years vs 31 years in the databases we used), and in
that study, patients older than 65 years had the highest rate of out-of-network
Many health plans are loosening their restrictions on patients' direct
access to specialists. This study provides insight into how patients will
use a self-referral option, even if it is associated with increased out-of-pocket
costs. The strength of patients' relationships with their regular physicians
was an important determinant of self-referral. In the claims analyses, greater
continuity of care, as measured by the proportion of all visits made to the
regular physician, was strongly associated with a lower probability of self-referral
to specialists. In the patient survey, 28% reported that they self-referred
because they disagreed with their physician about the need for specialty referral.
In another survey of Israeli patients, greater dissatisfaction with their
regular practitioner was associated with stronger preferences for self-referral.22 The implications of this finding are that some primary
care physicians may need training in communication and negotiation skills
with patients; health plans could also make it easier for patients to switch
primary care physicians; and patients may need education about the roles of
primary care physicians acting as gatekeepers.
About 1 in 5 survey respondents used their POS option to maintain ongoing
relationships with specialists. This finding was supported by the claims analyses
in which chronically ill patients had significantly increased odds of self-referral.
The size of the deductible in triple-option POS health plans progressively
increases from option 1 (physician-approved services) to option 3 (self-referral
out of network). In all 3 POS plans, having high out-of-pocket costs for physician-approved
(option 1) services significantly increased the odds of self-referral. For
such enrollees, the increased cost sharing associated with self-referral appeared
to be a weak disincentive, probably because there were already some out-of-pocket
expenses associated with gatekeeper-approved services.
The US health care system is seeking a new balance between the freedoms
and excesses represented by traditional open-access indemnity insurance system,
and the restrictions and coordination embodied in closed-network managed care
systems. The POS plan was developed as a hybrid of these 2 systems, and its
success depends on the degree to which the balance works.
The results of this study suggest that for the majority of POS enrollees,
simply having the option to bypass their regular physician is enough. For
those concerned that loosening gatekeeper restrictions will lead to huge increases
in uncontrolled utilization, our findings suggest that this is unlikely to
This study suggests that one advantage of the POS hybrid is that sicker
patients appear to make use of the options to bypass their regular physician
at greater rates than others. For example, patients with more complex and
numerous comorbidities, all else equal, were substantially more likely to
seek self-referrals. Our survey results underscore one benefit of such freedom
of choice: patients that avail themselves of self-referred specialist services
report higher satisfaction. Safran et al23
have found that survey-based measures of primary care performance were similar
among members enrolled in POS, managed indemnity, and network-model HMO health
plans, suggesting that the POS self-referral option does not compromise the
quality of primary care. That said, a careful assessment of some of the effects
of self-referrals on other dimensions of quality, particularly concerning
coordination of care,24 as well as overall
care efficiency awaits future research.
Over the last decade, medical educators and workforce analysts have
observed that tightly structured managed care plans like HMOs make greater
use of generalists and less use of specialists than do classic fee-for-service
plans.25 Some have suggested that as POS and
other open-access managed care plans increase in market share, so too will
our requirement for specialist physicians relative to generalists.26 A detailed assessment of the impact of POS plans
on the future needs for generalists vs specialists was not a main goal of
this analysis. However, based on our documentation of the relatively modest
rates of out-of-plan and self-referred specialist use by POS plan members,
this study suggests that the move toward POS plans will not dramatically alter
the predictions of workforce forecasters that based their projections on closed-network
For better or for worse, innovations in the private sector of the US
health care system have profound impact on patients, physicians, and all other
participants. As we redesign the structure of our health insurance plans in
pursuit of a well-balanced model, we must make sure we get the balance between
closed-network coordination and free-market flexibility right. The study reported
here suggests that to date, this appears to be the case with the POS plan,
though as this hybrid innovation grows in importance, so too must continued
assessment of the effects such a model is likely to have on all aspects of
US health care delivery.