Unraveling of gatekeeper concept may not be bad
December 1, 1997 3 minutes read
Unraveling of gatekeeper concept may not be bad
By Elizabeth Gallup, MD, JD, MBA
The advent of managed care brought with it a new role for the primary care physician: gatekeeper of health care services. Now managed care is backpedaling from the gatekeeper concept and defining a new role for primary care physicians: care manager. The difference is significant, and the transition makes sense. Primary care doctors, as well as specialists, should rejoice at this change occurring within most managed care organizations throughout the county. Primary care doctors are removed from the perceived role of being in charge of the HMO gate opening or closing. They no longer have to adhere to guidelines developed with little or no input from them.
Managed care plans typically define a gatekeeper as a physician whose approval is required before a patient can access specialists or hospital services. The rationale for the gatekeeper model was to decrease the performance of unnecessary tests, procedures, or referrals, which would theoretically decrease expenses. The primary care physician was designated as the gatekeeper because it was thought that the primary care physician, as a physician trained to diagnose and treat a broad spectrum of disease entities, was in the best position to determine the patient’s needs.
However valid the rationale of the gatekeeper model was in theory, many managed care plans are now discontinuing its use because it doesn’t "wash" practically or politically. One thing is certain: The gatekeeper model has contributed to the erosion of the physician-patient relationship, and the consumer backlash is fierce. Under the gatekeeper system, patients question whether their interests are uppermost in the minds of their physicians or the priorities of their health plans. Patients also worry about whether their physician is truly the gatekeeper of medical decisions, or if this power lies in the hands of case managers employed by managed care organizations.
Enrollees saw the guidelines and protocols of HMOs and MCOs as having the greatest influence on medical decision making, rather than their own doctor’s knowledge and judgment. Typically, these protocols are communicated to the practicing physician by dictate via a nonclinical person on the other end of a phone line. This process alienates the physician, as well as the patient. Moreover, recent research indicates that the gatekeeper model does not really hold down costs because most primary care physician requests for authorization for procedures or referrals are granted. A case in point is California-based PacifiCare, which last year initiated a system guaranteeing referrals to a select number of specialists within 24 hours (see related story, p. 170).
Thus, HMOs and MCOs are now moving away from the gatekeeper model and toward the care manager model, which allows primary care physicians to practice medicine in a way that reflects their training. Even when they refer patients to experts trained in other areas, primary care physicians remain in contact with the patient, managing the overall care of the patient while the specialist provides his or her care. Along the continuum of care, the primary care physician continues to coordinate the care provided by specialists, and makes sure the specialists communicate with each other and maintain the relationship with the patient. This model has been shown to decrease duplication of procedures, decrease the rate of performance of unnecessary procedures, and increase overall patient satisfaction.
It is appropriate for the primary care physician to be the manager of care. The training of a primary care physician prepares him or her to care for a vast array of illnesses and conditions, but not all of them. To provide the best care requires primary care doctors’ referral to specialists who are, as their name implies, specially trained to deliver care for a narrow spectrum of illness. The team effort of all physicians, with the primary care physician coordinating the efforts, promises to be the vehicle to provide the most comprehensive care to the patient in the most efficient manner.
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