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SACRAMENTO, Calif. -- Ignorance is the primary reason patients and doctors criticize health maintenance organizations for not providing easier access to specialists.
Many HMO patients don't know how to gain access to specialists, don't always know when referrals are appropriate and don't know how to appeal if they have trouble getting referrals. And many physicians don't adequately explain the referral process to patients because they themselves don't understand how it works.
Those were some of the findings of Consumer Health Access, a joint research project that seeks ways to give patients easier, more appropriate access to specialists without increasing HMO premiums.
Researchers concluded that the problem is two-sided: Patients are frustrated because they think the referral process takes too long, and doctors are frustrated because they think their patients have unrealistic expectations as to whether referrals really are needed. Doctors add that many patients don't understand the turnaround time in getting non-emergency appointments with busy specialists, who may be booked up weeks in advance.
"There has been a lot of criticism of the way HMOs provide access to specialists," said Kurato Shimada, a board member of California Public Employees Retirement System, one of the sponsors of the research project. "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 findings are the result of Phase One of the research project, which consisted of telephone surveys and focus groups to find out what problems patients and physicians are encountering.
While more than two-thirds of the patients participating in the telephone surveys and focus groups said they were satisfied with their HMOs, one-third said they have had problems with referrals to specialists.
Phase Two, now under way, will attempt to identify possible solutions to the problems uncovered by Phase One. Phase Three, which could take another year to complete and will start after completion of Phase Two, involves implementation of some of the proposed solutions in a pilot project. Phase Four will measure and evaluate how well those solutions work and will recommend best practices that will be disseminated to health care organizations throughout the nation.
No firm date has been set for completion of the four-part research project. A full written report on the Phase One findings will be released in late September.
In addition to CalPERS, other participants in the project include Health Net, the HMO arm of Woodland Hills, Calif.-based Health Systems International Corp.; California Health Decisions, a non-profit public education organization based in Orange, Calif.; Alta Bates Medical Group of Berkeley, Calif.; Hill Physicians Medical Group Inc. of Palo Alto, Calif.; Scripps Medical Associates of San Diego; and the Long Beach regional office of Med/Partners Inc. of Birmingham, Ala.