• It’s the gatekeepers, stupid

    Ulf Gerdtham and colleagues found that the overall cost of health care was generally lower in countries where primary care performs a gatekeeper function and patients can thus access secondary care only upon referral by a primary care professional. Diana Delnoij and colleagues showed that health care systems in which family physicians served as gatekeepers to more specialized care had a lower increase in ambulatory care costs and in the use of outpatient health services but not in total health care costs, compared to health care systems with directly accessible specialist care.

    From these studies we can infer that the gatekeeping function, usually coupled with patients’ being registered with a primary care doctor, seems to be a key element leading to lower health spending. However, patients do not express equal satisfaction with all aspects of primary care when gatekeeping is present.

    Madelon Kroneman and colleagues showed that patients in countries with a gatekeeping system were less satisfied with the quality of nonmedical aspects of primary care, such as convenience in obtaining an appointment or wait times in the office before seeing the doctor, than patients in countries with directly accessible specialists. However, differences in satisfaction with nonmedical aspects of access were not related to patients’ ratings of the quality of the actual care received, such as quick relief of symptoms.

    And, of course, we have the example of managed care in the 1990s U.S. It did some work, but patients and especially certain providers hated it. More from Dionne Kringos and colleagues in Health Affairs.


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    • Is there any evidence of increased satisfaction when insurers and providers ease the gatekeeper function when feasible? In my experience, the frustration stems from needing to see the primary care doc for a referral when the need for a specialist is obvious. If that could be done over the phone, via a triage nurse, for example….

      But I can tell you that, while the folks on my plan complain about the need for a referral, my coworkers on the other plans are complaining that their premium increase is nearly twice mine.

    • This is a little more evidence for my theory that our GP’s could and would help us get more for our money if they knew we were paying directly. They do not bother now because they are not so interested in saving money for insurance companies.

      This means contrary to what most people think the medical industry has an advantage over other industries like auto mechanics, home remodeling in that the GP does little of the high cost work himself and so can advocate with less bias for his patients.

    • I wonder if there have been any studies of practice scope of GPs in the US (where only 20% of doctors are GP) vs other developed nations (which usually have more like 80% GP).

      In my experience with doctors in both integrated systems and traditional fee-for-service clinic, the GP will refer to a specialist even for very minor or simple issues. Basically if it will take them more than 10 minutes to deal with it, you get a referral.

    • It is proven that NPs and PAs (midlevels) refer to specialists more often than doctors do.

      This is why NPs and PAs lead to HIGHER costs, not lower. Even if the PA only makes half of what an MD gets (which Obamacare outlaws by the way) they refer everybody to subspecialists who otherwise dont need them.

    • “In my experience, the frustration stems from needing to see the primary care doc for a referral when the need for a specialist is obvious. If that could be done over the phone, via a triage nurse, for example…”

      Your experience is wrong. Other countries dont utilize specialists as much as we do, and their costs are much lower as a result plus they get better healthcare outcomes than we do.

      There’s a lot of evidence to show that subspecialists drive up costs without providing much in return.

    • We tried this once (back in the 1990’s) when HMOs were just taking hold. All that happened was the primary care doc’s managed a lot more paperwork and spent more time filling out referral forms than seeing patients.

      It would be more cost (and care) effective to focus primary care on taking care of the patients with multiple chronic diseases and coordinating the care among the numerous specialists.

    • I’m not sure that the lower costs is due to the “gate-keeper” aspect per se. There’s a lot of evidence in the US that a big driver of costs is the fact that most people rely on emergency rooms for treatment, because they either do not have a primary care physician, or could not get a timely appointment with one. I suspect that the easiest way to reduce these costs would be to simply replace much of our existing primary care and emergency care with an on-demand urgent care model, and have social workers in emergency rooms triage people into urgent care when they don’t really have an emergency. This is something that a few hospitals in Oregon have started doing to reduce medicaid costs, and it seems to be working so far.