Visits to primary care physicians and to specialists under gatekeeper and point-of-service arrangements

Abstract

Objective: To assess utilization of ambulatory visits to primary care physicians (PCPs) and to specialists in 2 different managed care models: a closed panel gatekeeper health maintenance organization (HMO) and an open panel point-of-service HMO.

Study design: Retrospective study of patients enrolled in a single managed care organization with 2 distinct product lines: a gatekeeper HMO and a point-of-service HMO. Both plans shared the same physician network.

Patients and methods: The study sample included 16,192 working-age members of the gatekeeper HMO and 36,819 working-age members of the point-of-service HMO. We estimated the number of PCP and specialist visits using negative binomial regression models and predicted the number of visits per year for each person under each HMO type and copayment option.

Results: There were more annual visits to PCPs and a greater number of total physician visits in the gatekeeper HMO than in the point-of-service plan. However, we did not observe higher rates of specialist visits in the point-of-service HMO.

Conclusion: We found no evidence that direct patient access to specialists leads to higher rates of specialty visits in plans with modest cost-sharing arrangements.