Author Affiliations: Department of Family and Community Medicine (Dr Bodenheimer) and Program in Medical Ethics and Division of General Internal Medicine (Dr Lo), University of California at San Francisco School of Medicine; and Stanford Coastside Medical Clinic, Stanford, Calif (Dr Casalino).
Policy Perspectives Section Editors: Drummond Rennie, MD,
Deputy Editor (West), JAMA, and Robert J. Blendon, ScD.
Primary care gatekeeping, in which the goal of the primary
care physician (PCP) is to reduce patient referrals to specialists and
thereby reduce costs, is not an adequate system in which to practice
medicine. However, returning to the pre–managed care model of
uncoordinated open access to specialists is a poor solution. The
primary care model should be retained, but PCPs should be transformed
from gatekeepers into coordinators of care, in which the goal of the
PCP is to integrate both primary and specialty care to improve quality.
Changes in the PCP's daily work process, as well as the referral and
payment processes, need to be implemented to reach this goal. This
model would eliminate the requirement that referrals to specialists be
authorized by the primary care physician or managed care organization.
Financial incentives would be needed, eg, to encourage PCPs to provide
management of complex cases and discourage both overreferral and
underreferral to specialists. Budgeting specialists should control
excess costs that might be created by the elimination of the primary
care gatekeeper. Pilot projects are needed to test and refine this
model of PCP as coordinator of care.
Bodenheimer T, Lo B, Casalino L. Primary Care Physicians Should Be Coordinators, Not Gatekeepers. JAMA. 1999;281(21):2045–2049. doi:10.1001/jama.281.21.2045