A Case Study of Point-of-Service Medical Use in a Managed Care Plan

Abstract

This study examines the extent of point-of-service use in a managed care plan using 1990 and 1991 proprietary claims data (excluding pharmacy claims) from a large, well-established individual practice association with a point-of-service option. Results show that approximately 12 percent of all claims were made by out-of-network providers, representing about 9 percent of the dollar value of all claims. This is about $131 per enrollee per year. While younger enrollees (i.e., 6-24 years of age) use fewer medical resources than do older enrollees, they tend to receive a greater share of their medical services from out-of-network providers. There is little difference between point-of-service use by males and females. Mental illness is the most common diagnosis for out-of-network claims, accounting for about 25 percent of the dollar value of out-of-network claims. Ninety-six percent of the out-of-network claims for this diagnosis category were made by providers with a specialty in psychiatry.