November 26, 1997

Is Gatekeeping Better Than Traditional Care?A Survey of Physicians' Attitudes

Author Affiliations

From the General Internal Medicine Unit (Dr Halm) and the Health Policy Research and Development Unit (Drs Causino and Blumenthal), Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass. Dr Halm is now with the Department of Health Policy, Mount Sinai School of Medicine, New York, NY.

JAMA. 1997;278(20):1677-1681. doi:10.1001/jama.1997.03550200053031

Context.  —Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven.

Objective.  —To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost.

Design.  —Cross-sectional survey of primary care physicians

Setting.  —Outpatient facilities in metropolitan Boston, Mass.

Participants.  —All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded.

Outcomes Measures.  —Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care.

Results.  —Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physicianpatient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans.

Conclusions.  —Physicians identified both positive and negative effects of gatekeeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.