To the Editor.
—The Editorial1 by Dr Lundberg suggests that in his ideal world referral to a specialist or subspecialist be made only by the primary care physician. This is completely impracticable. Under most health maintenance organization plans, the primary care physician is supposed to act as a gatekeeper, but in fact this does not work. It merely means more effort wasted in purely bureaucratic administration, making out referral slips and calling up a clerk at the insurance company to get permission. Even if the specialist referral is unnecessary, no sensible physician would refuse a patient's request. If he or she did so, the patient would lose confidence and go to another primary care physician who would accede to the patient's wishes.The suggestion that primary care physicians not be given hospital admitting privileges is unsatisfactory. Often, a hospitalized patient does not require the care of the specialist, apart
Jacoby MG. JAMA Editorial Position and US Health System Reform. JAMA. 1994;272(21):1655. doi:10.1001/jama.1994.03520210039016