The Two Dominant Models
Employer health plans broadly fall into two structural categories: referral-based models (also called gatekeeper or closed-panel HMOs) that require employees to visit a designated primary care provider before accessing specialists, and open-access models (such as point-of-service or PPO plans) that allow direct specialist visits.
Each model carries distinct cost, utilization, and experience implications. The right choice depends on workforce demographics, budget constraints, and organizational priorities around employee autonomy versus cost predictability.
Cost Evidence: The RAND Findings
A widely cited RAND Corporation study that compared a closed-panel gatekeeper HMO with an open-panel point-of-service (POS) plan sharing the same provider network found that giving members unrestricted specialist access did not lead to significantly higher overall medical expenditures. Spending differences were small and not statistically significant.
A separate RAND study examining open access in the Federal Employees Health Benefits Program (FEHBP) reached a similar conclusion, finding that broader enrollment would have no significant effect on overall health spending. These findings suggest that the cost-saving advantage of gatekeeper designs may be more modest than commonly assumed.
Utilization Patterns
Referral-based plans generally exhibit higher primary care utilization but lower specialist visit frequency, since the gatekeeper step filters out some specialist referrals. Open-access plans tend to show earlier specialist engagement for chronic conditions, which some clinical literature suggests may lead to better long-term outcomes for certain conditions.
However, open-access plans also tend to show higher utilization of elective procedures and diagnostics. The net clinical and cost impact depends heavily on the specific population, provider network, and benefit design.
Employee Satisfaction and Hybrid Approaches
Employee satisfaction surveys consistently show higher scores for open-access plans, particularly among employees who value autonomy and speed of access. Referral-based plans score higher on cost predictability and are often preferred by finance teams.
A hybrid approach, where base-tier employees are enrolled in referral-based plans and senior employees receive open-access coverage, is increasingly common among employers seeking to balance cost and retention. Employers should weigh the evidence carefully rather than assuming that gatekeeper models deliver large savings.