Managed Care and Capitation in California: How Do Physicians at Financial Risk Control Their Own Utilization?

Abstract

Objective: To describe the structure and range of utilization management methods initiated by physicians in response to capitation.

Design: Cross-sectional questionnaire.

Setting: A large network-model health maintenance organization (133 contracting physician groups) in California.

Participants: 94 (71%) physician groups caring for 2.9 million capitated patients.

Measurements: Self-reported use of five major utilization management methods.

Results: All physician groups reported using gatekeeping and preauthorization for certain referrals or tests. Most also used profiling of utilization patterns (79%), guidelines (70%), and managed care education (69%). Most physician groups asked gatekeepers to submit preauthorization requests for specialty referrals and restricted patient self-referral. For example, 60% of groups required preauthorization for an internal medicine subspecialty referral, and 7% allowed patient self-referral. Most groups also asked gatekeepers to obtain preauthorization for many tests (for example, 95% for magnetic resonance imaging and 53% for pulmonary function tests). Preauthorization requests were denied infrequently (< 10% of the time) by more than 75% of groups. Of the 54 groups reporting utilization profiles to their physicians, 61% never adjusted for case-mix among patients and more than 60% suggested practice changes to their physicians based on utilization. Fewer than 35% of the groups used written guidelines for expensive tests that required preauthorization (such as angiography).

Conclusions: Physicians are responding to capitation by using utilization management techniques, some at early stages of development, that were previously used only by insurers. This physician-initiated management approach represents a fundamental transformation in the practice of medicine.