Resolving the Gatekeeper Conundrum

Abstract

High-quality primary care is the foundation of effective and efficient health care systems. Essential elements of the practice of primary care include accessibility as the first-contact point of entry to the health care system, continuity, comprehensiveness, coordination of referrals, and understanding of the family and community context of health.^1-6 Managed care organizations in the United States have tended to emphasize 2 of these tasks: providing first-contact care and coordinating referrals. Physicians performing these tasks are often referred to as "gatekeepers."^7,8 This term frequently has pejorative connotations in the United States due to concerns that the cost-containment imperatives of managed care encourage primary care physicians to restrict rather than facilitate access to specialists and other referral services. In 1997, almost half of all privately insured patients in major metropolitan regions throughout the United States were in "gatekeeping arrangements in which their primary care physician controls their access to specialists."⁹ The role of managed care gatekeepers in the United States has been especially contentious because of the use of economic incentives that may financially reward primary care physicians for thrifty use of referral and hospital services.^10,11