Dropping specialist referral does not boost use

When a Boston HMO gave patients direct access to specialists, it braced for a flurry of calls for appointments. The calls never came.

Until 1998, Harvard Vanguard Medical Associates, like other managed care plans required patients to get authorization from their primary care doctor before they could be seen by most specialists. Such "gatekeeping" policies are used to keep costs down and coordinate care.

But at Harvard Vanguard, the system was unpopular with doctors and patients alike, said Dr. Steven Pearson of Harvard Medical School, and a decision was made to drop it. A study by Pearson and his colleagues found that patients did not rush to specialists.

"Overall, there was a negligible change, really hard to pick up at all," Pearson said.

The study, published in Thursday's New England Journal of Medicine, was based on an analysis of doctor visits made by 60,000 patients during the three years before the policy was dropped and 30,000 patients after.

Little change recorded

On average, patients visited their primary care physician 1.21 times per six-month period before the change and 1.19 times after. The average number of visits to specialists was the same -- 0.78 times -- before and after gatekeeping.

The researchers found a small increase in first-time visits to specialists, with the most significant rise seen in those seeking treatment for back pain.

"The bottom line is that in this kind of system, you can offer open access to specialists without breaking the bank and without creating havoc," Pearson said. "And that's an important lesson for the health care system."

While the practice is subsiding, Pearson said about half of the people enrolled in managed health plans still face some referral requirements.

Harvard Vanguard, with 120 general internists and 50 specialists, is now an independent group practice. Until 1997, it was part of Harvard Pilgrim Health Care, a health plan whose foundation funded the study. Pearson's department at Harvard is a joint venture with Harvard Pilgrim.

The researchers said the results may not apply to other managed care plans or other groups of patients, a point emphasized by Dr. David Lawrence. He noted in an editorial that less than 5 percent of Americans receive care from group practices just as Harvard Vanguard.

Lawrence, chairman and chief executive officer of Kaiser Foundation Health Plan and Hospitals, said his health care plan strongly encourages patients to get referrals from their primary care doctors.

"If the patient is left to try and find his or her way through what is a maze of choices and a maze of different opinions and ideas about what should happen, the patient is really at rather substantial risk," he said.

A primary care doctor plays a critical role in helping the patient navigate.