Friday, October 19, 2001

Humana waives specialist referrals

But higher co-payments will apply to those appointments

By Tim Bonfield
The Cincinnati Enquirer

        Starting Jan. 1, more than 250,000 Tristate residents covered by Humana/ChoiceCare health plans will no longer have to get their primary-care physician's approval to see a specialist.

        Humana's new policy reflects a trend among health insurers nationwide to take some of the “manage” out of managed care while putting more decision-making authority — and financial responsibility — on the shoulders of individual consumers.

        “We've been working for some time now to get out of the middle of the clinical relationship between physicians and patients. ... We feel requiring referrals has become an old, non-effective tactic,” said Larry Savage, president and CEO of Humana Health Plan of Ohio Inc., which manages Humana/ChoiceCare plans in Greater Cincinnati.

        Effective Jan. 1, Humana/ChoiceCare enrollees can make appointments with any specialist listed in their plans without seeking approval from the insurer. But they will still need approval for hospital care and mental health services.

        But consumers will be charged a higher co-payment to see specialists than they would pay to see primary-care doctors. Health plan executives would not elaborate on those plans.

        And a new four-tiered pharmacy benefit that includes nearly all FDA-approved drugs will require Humana customers to pay higher co-payments for brand-name drugs than they would to take the generic medications.

        It's part of a long-term effort, Mr. Savage said, to encourage people to take more direct responsibility for their health care.

        “We've created the illusion that health care is cheap or free for many people. We have to begin changing consumer behavior,” he said.

        Humana/ChoiceCare is joining a growing number of health plans promoting more freedom of choice for consumers.

        Several years ago, United HealthCare Corp. made open access to specialists a central selling point of its plans. Then, in 1999, the company went another step by dropping the preauthorization requirement for hospital care.

        United has noticed several competitors nationwide launching similar versions of open access, said spokeswoman Nancy Newton.

        Anthem Blue Cross and Blue Shield, which covers about 400,000 Tristate residents, has been reforming its physician referral policies, too, as it rolls out new products and renews contracts, said Anthem spokesman Joe Bobbey.

        “We still encourage members to coordinate care through their primary-care physician but (members) are generally not being required to get Anthem's approval for referrals to specialists,” he said.

        Humana/ChoiceCare changed its policies for three reasons, Mr. Savage explained.

        • The company expects to save money by eliminating much of its claims review process.

        • The company hopes to please doctors, who complained for years about the second-guessing and paperwork hassles from HMOs.

        • The company shares more of its cost of new health technologies and overuse of health-care services with the consumers who use those services.

        For instance, most of Humana/ChoiceCare's plans don't charge a co-payment to obtain magnetic resonance imaging tests, “but if there was a $100 co-payment, people might start to think about whether that scan is necessary,” Mr. Savage said.


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