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Effect of a gatekeeper plan on health services use and charges: a randomized trial
D P Martin1, P Diehr, K F Price
1Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle 98195.
Insights
Physician gatekeepers in health plans can lower healthcare costs by reducing specialist visits. This randomized trial found gatekeeper plans reduced total charges by 6% compared to non-gatekeeper plans.
Area of Science:
- Health Services Research
- Healthcare Economics
- Clinical Practice Management
Background:
- Physician gatekeeping is a strategy used in managed care to control healthcare utilization and costs.
- The effectiveness of gatekeeper models in independent practice associations (IPAs) requires further investigation.
- Understanding the impact of gatekeepers on both overall and specific service charges is crucial for healthcare policy.
Purpose of the Study:
- To evaluate the effectiveness of a health care plan utilizing physician gatekeepers.
- To compare total healthcare charges and service utilization between gatekeeper and non-gatekeeper plans.
- To determine if gatekeeper incentives can reduce ambulatory care costs.
Main Methods:
- A randomized trial design was employed with new enrollees in United Healthcare (UHC).
- Participants were randomly assigned to either a standard UHC plan with a physician gatekeeper or an alternate plan without a gatekeeper.
- Demographic characteristics, perceived health status, and other insurance coverage were similar between groups.
Main Results:
- The gatekeeper plan demonstrated 6% lower total charges per enrollee compared to the non-gatekeeper plan.
- Minor differences were observed in hospital utilization and charges between the two plans.
- Ambulatory charges were significantly lower ($21 per person per year) in the gatekeeper plan, driven by a reduction in specialist visits (0.3 fewer visits).
Conclusions:
- Health plans incorporating physician gatekeepers with incentives and penalties can effectively reduce ambulatory service costs.
- Limiting specialist visits through a gatekeeper model is a key factor in cost reduction.
- The gatekeeper model shows potential for optimizing healthcare resource allocation and managing healthcare expenditures.
Abstract:
A randomized trial was conducted to determine the effectiveness of a health care plan which uses physicians as gatekeepers to control health services use and charges. New enrollees in United Healthcare (UHC), an independent practice association, were randomly assigned to the standard UHC plan requiring a gatekeeper, or to an alternate plan with equal benefits but without a gatekeeper. Individuals in both plans were similar in demographic characteristics, perceived health status, and other health insurance coverage. The gatekeeper plan had 6 percent lower total charges per enrollee than the plan without a gatekeeper. There were minor differences in hospital use and charges. Ambulatory charges were $21 lower per person per year in the plan with a gatekeeper (95% CI = -39.9, -2.1) and these were due to .3 fewer visits to specialists (95% CI = -0.50, -0.10). We conclude that a health plan which incorporates incentives and penalties for physicians to act as gatekeepers can reduce the cost of ambulatory services by limiting specialist visits.