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Chiropractic Research Review

Comparing Physician Expenditures under Managed Care

Although the shift toward increased provider choice appears to conflict with efforts to control health care costs, little data exist on the direct impact of alternative managed care models on the use of physician services.

Demonstration projects performed in the 1980s estimate that adding a primary care gatekeeper to a managed care plan could reduce costs by as much as 15% relative to indemnity insurance and improve quality of care by better coordinating the delivery of services. Despite this suggestion, much of the recent growth in managed care enrollment has involved plans with open physician panels and increased access to specialists.

This study compared overall expenditures for physician services in two Midwestern managed care models: a closed-panel gatekeeper health maintenance organization (HMO) and an open-panel point-of-service HMO. Main data sources utilized in the study were 1994-1995 administrative files on patients (16,825 patient records reviewed in the gatekeeper HMO and 39,129 members in the point-of-service HMO). Results are presented as follows:

* When co-payments for primary care physicians (PCPs) and PCP-referred specialist visits were $0, total physician expenditures were four percent higher in the gatekeeper HMO compared with the point-of-service HMO.

* When co-payments for PCPs and PCP-referred specialists were $10, no significant differences were noted in overall expenditures when comparing gatekeeper vs. point-of-service HMOs.

* When co-payments for PCP visits and PCP-referred specialists were $20, total physician expenditures ranged from equal in both HMOs to seven percent higher in the gatekeeper HMO (depending on the co-payment for self-deferred visits).

Conclusions: Direct patient access to specialists does not necessarily result in higher physician or specialist expenditures in HMOs, and in fact, may result in lower relative costs when comparing certain specific variables. The authors suggest future research to determine whether their findings are consistent across a broader spectrum of plan and patient populations.

Kapur K, Joyce GF, Van Vorst KA, et al. Expenditures for physician services under alternative models of managed care. Medical Care Research and Review, June 2000:57(2), pp161-81.

Chiropractic Research Review

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