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Is gatekeeping better than traditional care? A survey of physicians' attitudes
E A Halm1, N Causino, D Blumenthal
1Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA. ethanvhalm@smtplink.mssm.edu
Insights
Physician gatekeeping in managed care plans shows mixed results. While improving cost control and preventive care, it increases administrative burdens and negatively impacts care quality and physician autonomy.
Area of Science:
- Healthcare Management
- Health Services Research
- Primary Care Medicine
Background:
- Managed care plans widely employ physician gatekeepers to manage access to specialty and hospital services.
- The primary aims of gatekeeping are to reduce healthcare costs and enhance care quality through improved coordination and reduced inappropriate utilization.
- The actual effectiveness of gatekeeping in achieving these objectives remains largely unverified.
Purpose of the Study:
- To evaluate primary care physicians' perceptions of gatekeeping's impact compared to traditional care models.
- Assessing effects on administrative workload, patient care quality, resource utilization appropriateness, and overall cost.
Main Methods:
- A cross-sectional survey was administered to primary care physicians in metropolitan Boston.
- Participants included physicians acting as gatekeepers and traditional providers for specific employee groups.
- Physicians rated the impact of gatekeeping on 21 distinct aspects of medical care delivery.
Main Results:
- Physicians reported gatekeeping positively influenced cost control, preventive service use, and patient care knowledge.
- Conversely, gatekeeping was perceived to increase administrative tasks and negatively affect care quality, specialist access, and clinical decision-making freedom.
- Overall, 32% viewed gatekeeping as superior, 40% as equivalent, and 21% as inferior to traditional care.
Conclusions:
- Physicians perceive both advantages and disadvantages associated with the gatekeeper model.
- A significant majority (72%) considered gatekeeping to be equal to or better than traditional care arrangements.
Context:
Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven.
Objective:
To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost.
Design:
Cross-sectional survey of primary care physicians
Setting:
Outpatient facilities in metropolitan Boston, Mass.
Participants:
All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded.
Outcomes Measures:
Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care.
Results:
Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physician-patient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans.
Conclusions:
Physicians identified both positive and negative effects of gate-keeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.