Blue Shield, in Bold Move, Will Waive Specialist Referrals

Moving to address a major consumer complaint about HMOs, Blue Shield of California said Monday it will allow members to go directly to medical specialists without a referral from their primary physician, if they pay an extra $20 fee.

By letting patients go directly to specialists--a first in California and rare among HMOs nationally--Blue Shield is abandoning a cornerstone strategy of health maintenance organizations for controlling medical costs.

Nearly all HMOs have adopted a rigid referral system that requires members to get prior authorization to see cardiologists, dermatologists and other specialists.

Health-care experts generally praised the San Francisco-based insurer’s aggressive move, which they said will probably be popular with consumers and employers. But they also said the plan is fraught with problems.

They questioned, for example, whether Blue Shield can control costs as well as its competitors when it grants members greater access to specialists, which cost more.

But Blue Shield representatives said the program should not significantly boost medical costs or lead to increased member premiums. Company actuaries have estimated a “minimal increase� in members’ use of specialists, officials said.

There was no immediate comment from competitors, but experts said Blue Shield’s move is likely to pressure other HMOs into easing some of their policies on specialist referrals. The new program goes into effect Sept. 1 for Blue Shield’s 325,000 HMO members in California.

“I think we’re going to see more of this,� said Wayne Moon, Blue Shield chairman and chief executive.

The HMO industry has known for years that its limits on referrals to specialists are a major irritant for members. In some cases, patients complain of delays and red tape involved in seeing a specialist. And patients who are denied authorization to see a specialist may encounter a daunting bureaucratic maze if they decide to appeal the decision.

Surveys have found that anywhere from 15% to 25% of HMO members express dissatisfaction with their access to specialist care, Blue Shield said. With roughly 12 million Californians belonging to HMOs, that means as many as 3 million dissatisfied people.

Blue Shield’s is perhaps the most aggressive move yet by a major health plan to address consumer frustration with HMO policies that can make it difficult to see a specialist or get a second opinion.

“This is one of the earliest examples of what the marketplace is forcing HMOs to do,� said Alan Katz, a principal of Centerstone Insurance, a Woodland Hills-based insurance broker.

One of Orange County’s largest HMOs, PacifiCare of California, has taken steps to improve members’ access to health care and referrals to specialists by encouraging medical groups to come up with their own solutions, said Chris Wing, vice president and general manager.

Wing said PacifiCare invested about $250,000 to help two doctors’ groups--Santa Barbara-based Monarch Health System and an affiliate of St. Joseph Hospital in Orange--develop pilot programs last year.

The groups began allowing patients to see specialists without approval for most routine exams, such as mammograms. Referrals for serious conditions, such as cardiac troubles, still must get higher-level approval, he said.

Such changes resulted in a 60% reduction in the number of consumer complaints PacifiCare received on access and referral issues for the first quarter this year, compared with the same period last year, he said.

HMOs generally have tried to address the problem by offering point-of-service plans that allow members to see doctors outside the HMO’s approved network. However, these plans usually have significant deductibles--$250 or $500--and only partially reimburse members for out-of-network medical costs once the deductible is met. Also, premiums for point-of-service plans typically are 10% to 15% higher than regular HMOs.

Under the Blue Shield plan, patients can refer themselves to a specialist by making a $30 “co-payment.� That’s $20 more than Blue Shield’s usual $10 co-payment.

However, Blue Shield members can only refer themselves to a specialist within their chosen medical group; they won’t be free to pick any Blue Shield doctor or specialists outside the company’s network.

Also contributing to this report was Times staff writer Barbara Marsh.