title: Unlocking specialists' attitudes toward primary care gatekeepers.
abstract: OBJECTIVE
  Many managed care plans rely on primary care physicians to act as gatekeepers, which may increase tension between these physicians and specialists. We surveyed specialist physicians in California to determine whether their attitudes toward primary care gatekeepers differed depending on how the specialists were paid and the settings in which they practiced.
  
  
  METHODS
  We performed a cross-sectional survey using a mailed questionnaire. The predictors of specialist attitudes toward gatekeepers were measured using chi-square, the t test, and regression analyses.
  
  
  METHODS
  A probability sample of 1492 physicians in urban counties in California in the specialties of cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, and orthopedics was used.
  
  
  RESULTS
  We used questions about specialists' attitudes toward primary care physicians in the gatekeeper role. A summary score of attitudes was developed.
  
  
  RESULTS
  A total of 979 physicians completed the survey (66%). Attitudes toward primary care physicians were mixed. Relative to nonsalaried physicians, those who were salaried had a somewhat more favorable attitude toward gatekeepers (P = .13), as did physicians with a greater percentage of practice income derived from capitation (P =.002).
  
  
  CONCLUSIONS
  Specialists' attitudes toward the coordinating role of primary care physicians are influenced by the practice setting in which the specialists work and by financial interests that may be threatened by referral restrictions. Policies that promote alternatives to fee for service and shift specialty practice toward more organized group settings may generate a common sense of purpose among primary care physicians and specialists.
authors.affiliation: Department of Family and Community Medicine, University of California, San Francisco, USA. Penae@fcm.ucsf.edu.
authors.forename: E
authors.initials: E
authors.lastname: Pena-Dolhun
authors.forename: K
authors.initials: K
authors.lastname: Grumbach
authors.forename: K
authors.initials: K
authors.lastname: Vranizan
authors.forename: D
authors.initials: D
authors.lastname: Osmond
authors.forename: A B
authors.initials: AB
authors.lastname: Bindman
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002140:California; D016009:Chi-Square Distribution; D003430:Cross-Sectional Studies; D005260:Female; D020793:Gatekeeping / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D008329:Managed Care Programs; D008511:Medicine / Q000458:organization & administration / Q000706:statistics & numerical data*; D008875:Middle Aged; D010821:Physicians, Family / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012044:Regression Analysis; D013038:Specialization; D011795:Surveys and Questionnaires