Complaints About HMO Access to Specialists Often the Result of Doctor-Patient Misunderstanding.

SACRAMENTO, Calif.--(BW HealthWire)--Aug. 18, 1998--Much of the criticism of health maintenance organizations for not providing easier access to medical specialists is the result of doctors and patients not fully understanding how the HMO referral process works.

That was one of the research findings presented today to the Health Benefits Committee of the California Public Employees' Retirement System (CalPERS), the nation's second-largest public purchaser of employee health benefits behind the federal government.

The committee was told that one of the most "surprising" outcomes of the new research is the discovery that even the physicians themselves don't always understand precisely how the referral process works. Therefore physicians are not always able to fully explain the process to their patients.

The findings indicated that many patients don't know how to gain access to a specialist, don't always know when it's appropriate, and don't know how to appeal if they have trouble getting a referral from their primary care physician. Researchers concluded the problem is two-sided. Health care consumers are frustrated because they think the referral process takes too long, and physicians are frustrated because they feel their patients have unrealistic expectations as to whether a referral is really needed. Doctors say many patients don't understand the "turnaround time" in getting a non emergency appointment with a busy specialist, who may be booked up weeks in advance.

Those were some of the research findings by a joint project sponsored by CalPERS, Health Net, and several medical provider groups. The project, called Consumer Health Access, is seeking ways to give patients easier, appropriate access to specialists without unnecessarily increasing premium costs.

"There has been a lot of criticism of the way HMOs provide access to specialists," said Kurato Shimada, chair of the CalPERS Health Benefits Committee. "But, so far as we know, this is the first time any major, professional study has tried to find out precisely what the problems are, why they are occurring, and how to solve them."

The research findings were based on Phase One of the project, which consisted of telephone surveys and focus groups to find out what problems are being encountered by both patients and physicians. Phase Two, now underway, attempts to identify possible solutions to the problems uncovered by Phase One. Phase Three, which could take another year to complete, involves implementation of some of the proposed solutions as a pilot project. Phase Four will measure and evaluate how well those solutions work and recommend "best practices" which will be disseminated to health care organizations throughout the nation.

No firm date has been set for completion, because the project partners want to make certain there is adequate time to develop solutions that really work. But the CalPERS committee was told that it is already obvious that one recommendation will be better education of patients and doctors as to precisely how the specialist referral process is supposed to work. The research called for clearer referral explanations in HMO publications.

While over two-thirds of the members in the telephone surveys and focus groups were satisfied with their HMOs, one-third said they have had problems with referrals to specialists.

In addition to CalPERS and Health Net, other participants in the project include California Health Decisions, a non-profit public education organization which developed the consumer feedback loop process. Alta Bates Medical Group; Hill Physicians Medical Group Inc.; Scripps Medical Associates; and Med/Partners Inc. are the medical group partners.

A full written report on the research findings is expected to be released to the public in late September.

CalPERS is a national leader in efforts to stabilize health care premiums and improve patient satisfaction and medical quality. It purchases health benefits for more than 1 million public employees, retirees, and their families at 1,185 state and local government agencies throughout California. For more information on CalPERS, visit our Web site at www.calpers.ca.gov.

    CONTACT:  CalPERS Office of Public Affairs
               Bill Branch/Pat Macht, 916/326-3991