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Gatekeeping may not be cost effective

BMJ 2001; 323 doi: (Published 10 November 2001) Cite this as: BMJ 2001;323:1090
  1. Deborah Josefson
  1. San Francisco

    Restricting access to specialists through “gatekeeping” does not significantly reduce specialist referrals and is not necessarily cost effective, a new study has said (New England Journal of Medicine 2001;345:1312-7).

    Gatekeeping in the United States is the process of requiring insured patients to see a primary care doctor for an initial assessment and examination before being allowed to consult a specialist. As in the NHS in the United Kingdom, the US primary care doctors may choose to treat the patients themselves or to refer them for specialist care. The system has been widely embraced by both health maintenance organisations and traditional insurers as a cost containment method.

    In April of 1998 Harvard Vanguard Medical Associates, a multispecialty prepaid group practice (previously known as Harvard Community Health Plan) decided to eliminate the group's gatekeeping system and allowed patients to book specialist appointments direct.

    Researchers at Massachusetts General Hospital and Harvard Pilgrim Health Plans examined if the rates of visits to specialists differed before and after the lifting of a gatekeeping screen. Two sets of 10 000 health plan members were randomly selected, and their rates of visits to specialists were analysed during the three years before and 1.5 years after the gatekeeping screen was lifted.

    The researchers found that the rate of visits to primary care doctors and to specialists remained nearly constant. Adult patients visited a primary care doctor on average 1.21 times before and 1.19 times after the elimination of gatekeeping in a six month period (P=0.05).

    The average number of visits to specialists was 0.78 both before and after gatekeeping was ended (P=0.35). Moreover, visits to all doctors changed little before and after gatekeeping, with visits to specialists accounting for 39.1% of all visits to doctors before and 39.5% of all visits after.

    The percentage of first visits to specialists as a proportion of all visits to specialists increased slightly, however, from 24.7% to 28.2%. Complaints of low back pain probably accounted for most of this increase as visits with back pain problems to orthopaedic doctors and physical and occupational therapists increased from 26.6% to 32.9% (P=0.01). The study raises questions about the need for gatekeeping policies.

    Dr Timothy Ferris, one of the study's authors and a member of the Massachusetts General Hospital Institute for Health Policy, said: “The current study suggests that gatekeeper systems may be removed without creating a stampede of patients to specialty physicians. If gatekeeping isn't helping to control the costs of specialty medical care, the additional time and money spent on satisfying insurance company rules may not be worth it.”

    But in an editorial in the same issue of the New England Journal of Medicine Dr David Lawrence of the Kaiser Foundation Health Plan and Hospitals, Oakland, California, warned against “over-interpreting” the findings (p 1342). He said that from the late 1980s many managed care organisations introduced financial disincentives to deter primary care doctors from referring patients to specialist care. But these financial disincentives were later abandoned by many organisations.

    He said that the system then adopted by many organisations was to require patients to see a primary care doctor when they first sought care for a new illness, but that once he or she was referred to a specialist, no further referral was required for continued specialist care.

    “Another reason for caution, as Ferris et al. point out, is that their findings in an integrated, prepaid group practice cannot be generalised to medical care as a whole,” Dr Lawrence wrote.

    “Abandoning inappropriate gatekeeping models is appropriate. But, in my opinion, leaving medical consumers to choose within a poorly performing delivery system is irresponsible,” he concluded.

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