More often than not, plans are making compromises, keeping some form of gatekeeper controls but creating some special exemptions. Patients can't self-refer to, say, the highly specialized services of a pediatric neurologist, notes Kossman. Instead, the plan has given patients gatekeeper-free access to 12 commonly used specialists, such as cardiologists and dermatologists. It's just common sense, he says. But managed care may have gone too far in encumbering specialists and empowering primary care physicians.
Many people resent having to go to a doctor to get permission to go to another doctor.
Then there's giant United HealthCare, which has found success with both gatekeeper and open-access plans. Health plans can do quite well without either gatekeepers or disease-management schemes, Newcomer says. Just be sure that physicians have the right incentives, then track the results, he suggests. For one thing, he says, patients don't need to be driven to primary care physicians. Eighty percent of the patients in UHC's open-access Minnesota plan still visit their primary care physicians, even though nothing forces them do so.