[Implications of a general practitioner gatekeeping system in Germany]

Ambulatory healthcare in Germany is under pressure due to the increasing need for care, medical progress and a shortage of specialist personnel. Making general practitioners mandatory gatekeepers is on the political agenda aiming at more targeted use of specialist care and improved quality of care.

The study investigated how many persons in the statutory health insurance (SHI) currently consult specialists or psychotherapists without a referral and what additional burden a primary care system would place on general practitioners if these cases also had to be managed by them.

Based on nationwide physician billing data for all SHI patients in 2023, cases of adult SHI patients were selected in which a general practitioner contact fee ("hausärztliche Versichertenpauschale, VP") or a specialist or psychotherapeutic contact fee ("fachärztliche/psychotherapeutische Grundpauschale, GP") was claimed. Specialist or psychotherapy cases without a documented referral were considered as potentially uncontrolled. Various scenarios were considered to calculate the potential additional burden resulting from increased general practitioner control.

Out of 59 million insured adults 33.2 million visited a specialist or psychotherapist at least once without a documented referral. This was associated with 17-102 million potentially uncontrolled specialist or psychotherapy cases. If these had to be additionally managed by general practitioner in a gatekeeper system, this would imply approximately 335-2000 additional contacts per general practitioner per year, depending on the scenario.

The actual additional burden on general practitioner depends largely on the specific design of the primary care system. A moderate additional burden is likely and the decisive factor is a binding of patients for longer periods to the chosen primary care practice.