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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