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PROS Pearls:
* As part of the PROS Referral Process in Primary Care Study,
researchers examined how gatekeeping arrangements influence referrals
to specialty care for children and adolescents in private and
Medicaid insurance plans.
* Most office visits (55.6%) were for patients in plans with
gatekeeping arrangements. A larger proportion of patients with
private insurance (57.8%) were in gatekeeping plans than those
with Medicaid (43.4%).
* Contrary to popular belief, patients in gatekeeping plans were
more likely to be referred than patients not enrolled in gatekeeping
plans (3.16% vs 1.85% office visits for privately insured patients,
and 5.39% vs 3.73% of office visits for Medicaid-insured patients).
* Physicians who saw 75 percent or more of their patients in
gatekeeping plans saw 4 more patients per day (26 vs 22) than
those with 25 percent or fewer patients in gatekeeping plans.
Increased practice intensity could be associated with less time
to manage patients in the primary care setting, thereby leading
to more referrals, suggest the investigators.
* Coordination of referrals made during office visits was more
problematic at the time of referral for patients in gatekeeping
plans. Physicians were less likely to schedule an appointment
or communicate with the specialist for referred patients in gatekeeping
plans. Primary care physicians unfamiliar with the panel of specialists
in a patient's health plan may be less likely to contact that
consultant to schedule a referral visit or to provide information
about the patient.
* Researchers suggest that as market penetration of gatekeeping
insurance plans increases, physicians may need to hire additional
administrative staff to help them coordinate an increasing volume
of referrals.
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