• patient satisfaction;
  • access to specialists;
  • gatekeeping;
  • utilization management;
  • managed care

OBJECTIVE: To examine the influence of utilization review and denial of specialty referrals on patient satisfaction with overall medical care, willingness to recommend one’s physician group to a friend, and desire to disenroll from the health plan.

DESIGN: Two cross-sectional questionnaires: one of physician groups and one of patient satisfaction.

SETTING: Eighty-eight capitated physician groups in California.

PARTICIPANTS: Participants were 11,710 patients enrolled in a large California network-model HMO in 1993 who received care in one of the 88 physician groups.

MEASUREMENTS AND MAIN RESULTS: Our main measures were how groups conducted utilization review for specialty referrals and tests, patient-reported denial of specialty referrals, and patient satisfaction with overall medical care. Patients in groups that required preauthorization for access to many types of specialists were significantly (p≤ .001) less satisfied than patients in groups that had few preauthorization requirements, even after adjusting for patient and other group characteristics. Patients who had wanted to see a specialist in the previous year but did not see one were significantly less satisfied than those who had wanted to see a specialist and actually saw one (p < .001). In addition, patients who did not see a specialist when desired were more likely to want to disenroll from the health plan than patients who saw the specialist (40% vs 18%, p≤ .001) and more likely not to recommend their group to a friend (38% vs 13%, p≤ .001).

CONCLUSIONS: Policies that limited direct access to specialists, and especially denial of patient-desired referrals, were associated with significantly lower patient satisfaction, increased desire to disenroll, and lower likelihood of recommending the group to a friend. Health plans and physician groups need to take these factors into account when designing strategies to reduce specialty care use.