BMJ 2003;326:692-695 ( 29 March )

Primary care

Primary care in the United States

Primary care gatekeeping and referrals: effective filter or failed experiment?

Christopher B Forrest, associate professor. 

Health Services Research and Development Center, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA

cforrest@jhsph.edu

The first 150 words of the full text of this article appear below.

The use of primary care physicians as gatekeepers to specialists and other medical resourcesconsidered to be a managed care innovation in the United Stateshas proliferated during the past few decades. Its introduction has been accompanied by a government sponsored programme of research into referrals from primary care (box 1). Findings from these studies may offer insights into how the UK's NHS could shape the gatekeeping function of general practitioners. This article discusses the concept of gatekeeping, contrasts the processes of referral to specialists in the United States and the United Kingdom, examines the mechanisms by which gatekeeping influences resource allocation, and discusses the effects of linking gatekeeping with financial incentives and utilisation review.

Summary points Gatekeeping systems have emerged in countries with scarce medical resources Gatekeepers ensure equity by judiciously matching healthcare services, including specialty referrals, to healthcare needs Gatekeeping alters patients' behaviour, increasing levels of first contact care with primary care physicians, thereby reducing patients' self referrals Patients in US health plans with gatekeeping arrangements are twice as likely to be referred to specialist care as their UK counterparts There is little evidence that gatekeeping has had much effect on patients' referral rates in the United States, a healthcare environment rich in specialists

	Gatekeeping in the United States and the United Kingdom

Within modern societies, gatekeepers are positioned between organisations and individuals who wish to use resources within those organisations. Gatekeepers use discretion when determining who will be granted access to these resources. Physician gatekeepers collaborate . . . [Full text of this article]

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