Is gatekeeping better than traditional care? A survey of physicians' attitudes.
BACKGROUND
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.


METHODS
Cross-sectional survey of primary care physicians


METHODS
Outpatient facilities in metropolitan Boston, Mass.


METHODS
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.


METHODS
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.
Halm
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EA
Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA. ethanvhalm@smtplink.mssm.edu
Causino
N
N
Blumenthal
D
D
D001291:Attitude of Health Personnel; D001900:Boston; D003430:Cross-Sectional Studies; D003625:Data Collection; D005194:Family Practice / Q000191:economics / Q000592:standards; D018588:Fee-for-Service Plans / Q000191:economics / Q000592:standards*; D017048:Health Care Costs; D019538:Health Care Surveys; D006279:Health Maintenance Organizations / Q000191:economics / Q000592:standards; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D010821:Physicians, Family / Q000145:classification / Q000523:psychology / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D012044:Regression Analysis; D040841:Resource Allocation; D018570:Risk Assessment; D011795:Surveys and Questionnaires