Kaiser Permanente has never required health plan preauthorization to see a specialist, and now it's not always necessary to see your primary care physician for a referral. The Fairfield Medical Office in Northern California, for example, is one of several clinics in the Region which offers direct access to physical therapy. If healthy adults with acute muscular or skeletal injury have not previously seen a primary care doctor for their conditions and the problem is not the result of an industrial injury, they can self-refer to the clinics.

"This frees up medical appointments by allowing patients without other medical problems to go directly to the clinics," notes Beverly Suits, director of physical therapy at Fairfield. The open access is a real patient-pleaser, as well; in a recent survey, 99% of patients rated the service "excellent."

According to Dianne Preston, medical group administrator for the South San Francisco Medical Center, when treatments at her center fall within certain practice guidelines, patients may self-refer to physicians in urology, general surgical orthopedics, ophthalmology, dermatology, surgery, head and neck, allergy, and neurology. In addition, South San Francisco's emergency department may directly schedule specialist appointments for patients who require follow-up treatment, without first obtaining a referral from a primary care physician.

Kaiser Permanente's Northwest Division, which includes Portland, Ore., and portions of Washington, offers patients standing orders that allow them to receive adult immunizations without a prior doctor visit.

"One of Kaiser Permanente's objectives is to give members care when they want it, without any roadblocks," says John McGrory, MD, administrator of Kaiser Permanente's Franklin Medical Center in Colorado.

KP is also experimenting with new ways to make specialist access easier and faster for primary care physicians who find themselves in need of a consult with a system of cell phone specialty networks. "Gut Check," "Heart Check," and the "Bone Phone" make dedicated gastroenterologists, cardiologists and orthopedists available immediately to primary care physicians while their patients are still in the office. There's no waiting days or even overnight to find out "what the specialist says."

In addition to answering questions, the specialist may offer a diagnosis or suggest a course of treatment. At the same time, the PCP may also arrange a patient appointment with the specialist if necessary.

"The conversation enables members to properly prepare for the visit with the specialist by getting appropriate tests in advance," says Dr. McGrory. Franklin Medical Center uses cell phone networks for both "Gut Check" and "Heart Check." He has seen appointment wait time for gastroenterologists drop from 23 to three days due to the cell phones.

"In addition, the use of the phones empowers and educates the primary care physician while also eliminating repeat diagnoses or duplication of services," he adds.