"We found that there was a very small increase in new visits to specialists, but that overall there was no change in rates of specialist visits," says lead author Timothy G. Ferris, MD, of the MGH Institute for Health Policy. "And because the cost and inconvenience of gatekeeping to physicians and patients are great, we may want to re-evaluate the policy."
Gatekeeping is a requirement by many health insurers that a primary care physician authorize all specialist visits. Without this prior authorization, the insurance company will not pay for the specialist visits. "Previous research has shown that gatekeeping has some effect on decreasing costs of care in certain expensive populations, such as Medicaid patients, but commercial insurers adopted this policy in the 1980s with little knowledge about effects in commercially insured populations," says Ferris.
Ferris adds that patients and doctors generally do not like gatekeeping. "Patients dislike having to contact one physician before going to see another," he says. "And it costs doctors both time and money. It takes time for physicians to write up the referrals, and extra staff must be hired to make sure all of the paperwork is done." The current study suggests that gatekeeper systems may be removed without creating a stampede of patients to specialist physicians. If gatekeeping isn?t helping to control the costs of specialty medical care, the additional time and money spent on satisfying insurance company rules may not be worth it, the researchers say.
In 1998, Harvard Vanguard Medical Associates dropped their gatekeeping requirement. The researcher team checked to see if this change resulted in more visits to specialists. "The only real increase we found was in patients who went to see specialists for back pain, indicating there may be some pent-up demand to see specialists for this condition," Ferris says. He and his colleagues analyzed patient visits during six-month periods for the 3 years before and 18 months after gatekeeping was eliminated. In each period, the scientists looked at randomly selected cohorts of 10,000 patients cared for by Harvard Vanguard Medical Associates physicians.
In the six-month periods before and after the elimination of gatekeeping, adults visited primary care physicians an average of 1.21 times and 1.19 times, respectively. The average number of visits to specialists was 0.78 per six-month period both before and after gatekeeping was eliminated. There was no significant change in the percentage of visits to specialists as a proportion of all visits, but the percentage of first visits to specialists increased from 23.7 to 28.2 percent. The proportion of visits to specialists for low back pain that were new consultations increased from 26.6 to 32.9 percent.
Ferris stresses that, while communication between primary care physicians and specialists is important, gatekeeping policies may not be an effective way to promote it. "Health care managers and policy makers evaluating their gatekeeping policies will need to consider strategies to promote care coordination while simultaneously freeing patients and providers from ineffective bureaucratic procedures," he says. Because approximately 50 percent of Americans are in health care plans with gatekeeping requirements, this issue affects millions of individuals.
Other MGH and Harvard Medical School researchers involved in the study include Yuchiao Chang, PhD, and David Blumenthal, MD, MPP, also of the MGH Institute for Health Policy; and Steven Pearson, MD, MSc, of HPHC. Support for this study was provided by the HPHC Foundation.
The Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $300 million and major research centers in AIDS, the neurosciences, cardiovascular research, cancer, cutaneous biology, transplantation biology and photomedicine. In 1994, the MGH joined with Brigham and Women?s Hospital to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups and nonacute and home health services.
Journal
New England Journal of Medicine