title: Economic efficiency of gate-keeping compared with fee for service plans: a Swiss example.
abstract: OBJECTIVE
  The impact of isolated gate-keeping on health care costs remains unclear. The aim of this study was to assess to what extent lower costs in a gate-keeping plan compared with a fee for service plan were attributable to more efficient resource management, or explained by risk selection.
  
  
  METHODS
  Year 2000 costs to the Swiss statutory sick funds and potentially relevant covariates were assessed retrospectively from beneficiaries participating in an observational study, their primary care physicians, and insurance companies. To adjust for case mix, two-part regression models of health care costs were fitted, consisting of logistic models of any costs occurring, and of generalised linear models of the amount of costs in persons with non-zero costs. Complementary data sources were used to identify selection effects.
  
  
  METHODS
  A gate-keeping plan introduced in 1997 and a fee for service plan, in Aarau, Switzerland.
  
  
  METHODS
  Of each plan, 905 randomly selected adult beneficiaries were invited. The overall participation rate was 39%, but was unevenly distributed between plans.
  
  
  RESULTS
  The characteristics of gate-keeping and fee for service beneficiaries were largely similar. Unadjusted total costs per person were Sw fr 231 (8%) lower in the gate-keeping group. After multivariate adjustment, the estimated cost savings achieved by replacing fee for service based health insurance with gate-keeping in the source population amounted to Sw fr 403-517 (15%-19%) per person. Some selection effects were detected but did not substantially influence this result. An impact of non-detected selection effects cannot be ruled out.
  
  
  CONCLUSIONS
  This study hints at substantial cost savings through gate-keeping that are not attributable to mere risk selection.
authors.affiliation: ECPM Research, c/o ECPM Executive Office, University Hospital, CH-4031 Basle, Switzerland. m.schwenkglenks@unibas.ch
authors.forename: Matthias
authors.initials: M
authors.lastname: Schwenkglenks
authors.forename: Georges
authors.initials: G
authors.lastname: Preiswerk
authors.forename: Roman
authors.initials: R
authors.lastname: Lehner
authors.forename: Fritz
authors.initials: F
authors.lastname: Weber
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Szucs
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002204:Capitation Fee; D003953:Diagnosis-Related Groups / Q000191:economics; D017598:Efficiency, Organizational / Q000191:economics*; D018588:Fee-for-Service Plans / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D020793:Gatekeeping / Q000191:economics*; D017048:Health Care Costs; D006801:Humans; D015273:Insurance Selection Bias; D007357:Insurance, Physician Services / Q000191:economics*; D008297:Male; D008329:Managed Care Programs / Q000191:economics* / Q000706:statistics & numerical data; D008875:Middle Aged; D012044:Regression Analysis; D013557:Switzerland