Gatekeeping and patterns of outpatient care post healthcare reform

As US healthcare spending increases, insurers are focusing attention on decreasing potentially avoidable specialist care. Little recent research has assessed whether the design of modern health maintenance organization (HMO) insurance is associated with lower utilization of outpatient specialty care versus less restrictive preferred provider organization (PPO) plans.

Observational study of Massachusetts residents aged 21 to 64 years with any HMO or PPO insurance coverage from 2010 to 2013.

We examined rates and patterns of primary care visits, new specialist visits, and specialist spending among HMO versus PPO enrollees. We estimated multivariable regression models for each outcome, adjusting for patient and insurance characteristics.

From 2010 to 2013, 546,397 and 295,427 individuals had continuous HMO or PPO coverage, respectively. HMO patients had fewer annual new specialist visits per member versus PPO patients (unadjusted, 0.37 vs 0.43), a difference after adjustment of 0.05 annual visits, or a 12% relative decrease among HMO members (P <.001). These visits were more likely to be with a specialist in the same health system as the patient's primary care physician (44.9% vs 40.7%; adjusted difference, 2.8 percentage points; P <.001). Mean annual spending on new specialist visits and subsequent follow-up per member was lower in HMO versus PPO patients (unadjusted, $104.10 vs $128.10), translating to 12% lower annual spending (adjusted difference, -$16.26; P <.001).

Having HMO insurance was associated with lower rates of new specialist visits and lower spending on specialist visits, and these visits were less likely to occur across multiple health systems. The impact of this change on overall spending and clinical outcomes remains unknown.