Effect of a gatekeeper plan on health services use and charges: a randomized trial

Effect of Having a Usual Source of Care on Medical Expenses - Using the Korea Health Panel Data

BACKGROUND

There is a controversy about the effect of having a usual source of care on medical expenses. Although many studies have shown lower medical expenses in a group with a usual source of care, some have shown higher medical expenses in such a group. This study aimed to empirically demonstrate the effect of having a usual source of care on medical expenses.

METHODS

The participants included those aged 20 years and older who responded to the questionnaire about "having a usual source of care" from the Korean Health Panel Data of 2012, 2013, and 2016 (6,120; 6,593; and 7,598 respectively). Those who responded with "I do not get sick easily" or "I rarely visit medical institutions" as the reasons for not having a usual source of care were excluded. The panel regression with random effects model was performed to analyze the effect of having a usual source of care on medical expenses.

RESULTS

The group having a usual source of care spent 20% less on inpatient expenses and 25% less on clinic expenses than the group without a usual source of care. Particularly, the group having a clinic-level usual source of care spent 12% less on total medical expenses, 9% less on outpatient expenses, 35% less on inpatient expenses, and 74% less on hospital expenses, but 29% more on clinic expenses than the group without a usual source of care.

CONCLUSION

This study confirmed that medical expenses decreased in the group with a usual source of care, especially a clinic-level usual source of care (USC), than in the group without a usual source of care. Encouraging people to have a clinic-level USC can control excessive medical expenses and induce desirable medical care utilization.

The effects of gatekeeping on the quality of primary care in Guangdong Province, China: a cross-sectional study using primary care assessment tool-adult edition

Background

Developed countries have widely implemented a gatekeeping system as a core policy of primary care, also known as the system of first visit in the community. As gatekeepers, general practitioners are responsible for the diagnosis and treatment of residents in the community health centres, and referring patients to specialists as appropriate. After several years of healthcare reform, gatekeeping policy has achieved remarkable success in China. Shenzhen and Dongguan were the first batch of pilot cities that implemented the policy of gatekeeping. This study aims to examine the effects of gatekeeping on the quality of primary care between the gatekeeping and non-gatekeeping groups in these two pilot cities.

Methods

A cross-sectional survey was conducted in five community health centres in Shenzhen and Dongguan cities, both located within Guangdong Province, China, using a validated Chinese version of the Primary Care Assessment Tool-Adult Edition (PCAT-AE) and carrying out face-to-face interviews with patients 18 years and older. Analyses were grouped according to whether or not patients had gatekeepers. Propensity Score Matching was used to control for confounding factors. A chi-square test was used to compare the factors mentioned above and an independent t-test was performed to compare the eight domains of the core functions of primary care between the two groups of patients.

Results

In total, 765 valid questionnaires were collected for analysis, after matching the sample size were 238 pairs. All the confounding factors observed between the gatekeeping and non-gatekeeping groups were balanced. The PCAT-AE scores for first-contact utilisation (3.29 > 2.66, p < 0.001) and coordination (2.06 > 1.95, p < 0.05) were higher in the gatekeeping group after matching, but the domains of accessibility (1.59 < 1.67, p < 0.05) and continuity (2.26 < 2.40, p < 0.05) were lower. The PCAT-AE mean score was slightly higher in gatekeeping group (1.98 > 1.93, p > 0.05) but without statistical significance.

Conclusion

This study demonstrated that gatekeeping has helped to improve first-contact utilisation and coordination of primary care, but that other goals such as continuity and comprehensiveness have been harmed. To establish a sustainable gatekeeping system and to strengthen the core functions of the community comprehensively, the current gatekeeping system needs refinement.

Costs and efficiency of gatekeeping under varying numbers of general practitioners

We study the relationship between gatekeeping on one hand and costs as well as efficiency on the other hand. We do this with special focus on the relative amount of general practitioners in the system when compared with all practitioners. Data collected between 2002 and 2011 by The Organization for Economic Co-operation and Development on 34 countries were analyzed. Of those, 18 countries have gatekeeping systems while 16 do not. The association between gatekeeping and health care costs was examined with regression analysis. Efficiency was assessed with data envelopment analysis. Finally, the efficiency assessments were analyzed with regression techniques to examine if gatekeeping and/or the ratio of GPs to all practitioners was associated with efficiency. Point estimates indicate that total costs tend to be lower in systems where GPs act as gatekeepers. However, efficiency is slightly lower where gatekeeping exists. Neither of these results is statistically significant at the 95% confidence level. There is also indication that the efficiency of a gatekeeping system increases with increased amount of GPs. When GPs are over 30% of practitioners, gatekeeping countries have more efficient health care systems than their counterparts. Consistent with other studies, we estimate income elasticity of health care demand to be 1.12, suggesting that those societies consider health care to be a luxury good.

Factors influencing government insurance scheme beneficiary acceptance of the gatekeeper policy: a cross-sectional study in Wuhan, China

BACKGROUND

Gatekeeper policy, requiring a patient to visit a primary care provider first, and the patient needs to get his or her primary care provider's referral before seeing a specialist or going to a hospital, has been implemented in China for about ten years, and it is necessary to assess the patients' acceptance of gatekeeper policy and to explore the factors influencing patients' acceptance.

METHODS

A cross-sectional study with 1162 respondents was conducted between July and September 2015 at four community health centers (CHCs) in Wuhan, China. Face-to-face interview was used to collect information on demographics, acceptance of the gate keeper policy and satisfaction with community health services. Patients' satisfaction with community health service was evaluated using the European Patients Evaluate General/Family Practice scale and binary logistic regression model was used to examine the factors influencing patients' acceptance of community health services as gate keepers.

RESULTS

A total of 512 (43.06%) patients accepted gatekeeper policy. Mandatory reimbursement provision (OR: 1.63, 95% CI: 1.23-2.15), patient satisfaction with the aspects of medical care (OR: 1.92, 95% CI: 1.12-3.29) and organization of care (OR: 1.66, 95% CI: 1.05-2.62) were associated with acceptance of gatekeeper policy, after adjusting for potential confounders. Moreover, young people (OR: 0.35, 95%CI: 0.22-0.56) seemed to be more reluctant to accept the policy, when compared with the elder.

CONCLUSIONS

Our study suggests that mandatory reimbursement provision greatly affects patients' acceptance of gatekeeper policy, therefore, the policy-maker should pay attention to the negative effect of its mandatory reimbursement provision on patients' acceptance of the policy. However, improving the aspects of medical care and organization of care will contribute to implementation of gatekeeper policy.

Impact of regional socioeconomic variation on coordination and cost of ambulatory care: investigation of claims data from Bavaria, Germany

OBJECTIVES

A considerable proportion of regional variation in healthcare use and health expenditures is to date still unexplained. The aim was to investigate regional differences in the gatekeeping role of general practitioners and to identify relevant explanatory variables at patient and district level in Bavaria, Germany.

DESIGN

Retrospective routine data analysis using claims data held by the Bavarian Association of Statutory Health Insurance Physicians.

PARTICIPANTS

All patients who consulted a specialist in ambulatory practice within the first quarter of 2011 (n=3 616 510).

OUTCOMES MEASURES

Of primary interest is the effect of district-level measures of rurality, physician density and multiple deprivation on (1) the proportion of patients with general practitioner (GP) coordination of specialist care and (2) the mean amount in Euros claimed by specialist physicians.

RESULTS

The proportion of patients whose use of specialist services was coordinated by a GP was significantly higher in rural areas and in highly deprived regions, as compared with urban and less deprived regions. The hierarchical models revealed that increasing age and the presence of chronic diseases are the strongest predictive factors for coordination by a GP. In contrast, the presence of mental illness, an increasing number of medical condition categories and living in a city are predictors for specialist use without GP coordination. The amount claimed per patient was €10 to €20 higher in urban districts and in regions with lower deprivation. Hierarchical models indicate that this amount is on average higher for patients living in towns and lower for patients in regions with high deprivation.

CONCLUSION

The present study shows that regional deprivation is closely associated with the way in which patients access primary and specialist care. This has clear consequences, both with respect to the role of the general practitioner and the financial costs of care.

Gatekeeping and the utilization of community health services in Shenzhen, China: A cross-sectional study

To assess the effects of the gatekeeper policy implemented in Shenzhen, China, in conjunction with a labor health insurance program, on channeling patients toward community health centers (CHCs).Eight thousand patients who visited 8 CHCs in Shenzhen were surveyed between May 1, 2013 and July 28, 2013. Half of the patients were subject to gatekeeper policy and the other half of them were not. Structured questionnaire was used to collect patients' choices of initial medical institution, use of CHCs and their satisfaction with health care. Bivariate and regression analyses were used to compare patient's choice, utilization, and satisfaction of CHCs.Compared with patients who were free to seek medical care at any place, patients with gatekeepers were 1.77 (95% CI 1.37-2.30) times more likely to choose CHCs first when seeking care. In the past year, the group with gatekeeper made 0.88 more visits to CHCs in the past year than the group without gatekeeper (P < .01), controlling for influencing factors. The 2 groups were equally satisfied with all satisfaction measures except for "waiting time," which was higher among patients without gatekeepers (P < .01).Our study indicates that, as repeatedly proven in other parts of the world, gatekeeping is effective in orienting patients toward primary care system. Along with increased efforts in rebuilding China's primary care network and expanding health insurance coverage, implementation of gatekeeper policy may help increase access to care, reduce inappropriate use of health resources, and strengthen primary care institutions.

Implementation of a pilot accountable care organization payment model and the use of discretionary and nondiscretionary cardiovascular care

BACKGROUND

Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures.

METHODS AND RESULTS

The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures among patients of PGPD practices compared with patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% confidence interval, -0.51% to 0.85%; P=0.595) or discretionary coronary imaging (-0.19%; 95% confidence interval, -0.73% to 0.35%; P=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% confidence interval, -0.008% to 0.002%; P=0.705) and coronary revascularization (-0.02%; 95% confidence interval, -0.11% to 0.07%; P=0.06). The difference-in-difference associated with PGPD implementation was also essentially 0 for nondiscretionary cardiovascular imaging or procedures.

CONCLUSION

Implementation of a pilot accountable care organization did not limit the use of discretionary or nondiscretionary cardiovascular care in 10 large health systems.

Australian optometric and ophthalmologic referral pathways for people with age-related macular degeneration, diabetic retinopathy and glaucoma

BACKGROUND

This study investigated the referral pathways offered to patients with age-related macular degeneration (AMD), diabetic retinopathy (DR) or glaucoma (GL) by ophthalmologists and optometrists.

METHODS

Australian ophthalmologists and optometrists were surveyed regarding referral decisions to other eye-care specialists (inter- or intra-professional), general medical practitioners (GPs), low vision rehabilitation (LVR) and support services. Thematic analysis and concept mapping were applied to highlight current and ideal referral pathways.

RESULTS

The survey was completed by 155 optometrists and 50 ophthalmologists and deemed representative of their respective professions in Australia. Not surprisingly, the vast majority of the participating optometrists (97 to 99 per cent) referred to ophthalmologists regardless of the underlying condition. Clear differences (Chi-square: p < 0.05) were observed in the referral patterns of optometrists and ophthalmologists to GPs and support services. General medical practitioner services were almost exclusively used for patients with DR, while AMD triggered a significantly higher referral rate to low vision rehabilitation and support services than the other two disorders.

CONCLUSION

While ophthalmologists predominantly referred patients with AMD, DR or GL to low vision rehabilitation services, optometrists' referrals were highly skewed toward ophthalmology. Referrals to other supporting services by the two groups were not greatly used. The perceived referral pathways by the two eye-care professionals suggested a unidirectional route, potentially highlighting the need for a more collaborative approach that facilitates optimal use of eye health care and allied services.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement

OBJECTIVE

The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society.

CONCLUSIONS

Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review

Background

Emergency department (ED) utilization has dramatically increased in developed countries over the last twenty years. Because it has been associated with adverse outcomes, increased costs, and an overload on the hospital organization, several policies have tried to curb this growing trend. The aim of this study is to systematically review the effectiveness of organizational interventions designed to reduce ED utilization.

Methodology/Principal Findings

We conducted electronic searches using free text and Medical Subject Headings on PubMed and The Cochrane Library to identify studies of ED visits, re-visits and mortality. We performed complementary searches of grey literature, manual searches and direct contacts with experts. We included studies that investigated the effectiveness of interventions designed to reduce ED visits and the following study designs: time series, cross-sectional, repeated cross-sectional, longitudinal, quasi-experimental studies, and randomized trial. We excluded studies on specific conditions, children and with no relevant outcomes (ED visits, re-visits or adverse events). From 2,348 potentially useful references, 48 satisfied the inclusion criteria. We classified the interventions in mutually exclusive categories: 1) Interventions addressing the supply and accessibility of services: 25 studies examined efforts to increase primary care physicians, centers, or hours of service; 2) Interventions addressing the demand for services: 6 studies examined educational interventions and 17 examined barrier interventions (gatekeeping or cost).

Conclusions/Significance

The evidence suggests that interventions aimed at increasing primary care accessibility and ED cost-sharing are effective in reducing ED use. However, the rest of the interventions aimed at decreasing ED utilization showed contradictory results. Changes in health care policies require rigorous evaluation before being implemented since these can have a high impact on individual health and use of health care resources. Systematic review registration: http://www.crd.york.ac.uk/PROSPERO. Identifier: CRD420111253

The effects of gatekeeping: a systematic review of the literature

OBJECTIVE

To assess the effects of physician-centred gatekeeping on health, health care utilization, and costs by conducting a systematic review of the literature.

METHODS

Systematic search in PubMed (MEDLINE and Pre-MEDLINE), EMBASE, and the Cochrane Library, from the databases' respective inception dates up to January 2010, using the search words "gatekeeping", "gatekeeper*", "first contact", and "self-referral". We included RCTs, CCTs, cohort studies, CBAs, and interrupted time-series. We included only studies in which the gatekeeper function was exercised by a physician and that reported health and patient-related outcomes including quality of life and satisfaction, quality of care, health care utilization, and/or economic outcomes (e.g. expenditures or efficiency). Selection was made independently by two reviewers and discrepancies were solved by consensus after discussion. Data on target population, intervention, additional interventions, study results, and methodological quality were extracted. Methodological quality was assessed independently by two reviewers following the previously defined criteria. Discrepancies were solved by consensus after discussion.

RESULTS

This review includes 26 studies in 32 publications. The majority of studies (62%) reported data from the United States and in most gatekeeping was associated with lower utilization of health services (up to -78%) and lower expenditures (up to -80%). However, there was great variability in the magnitude and direction of the differences.

CONCLUSION

Overall, the evidence regarding the effects of gatekeeping is of limited quality. Many studies are available regarding the effects on health care utilisation and expenditures, whereas effects on health and patient-related outcomes have been studied only exceptionally and are inconclusive.

A qualitative study of the difficulties in reaching sustainable universal health insurance coverage in Iran

OBJECTIVE To understand the Iranian health financing system and provide lessons for policy makers about achieving universal coverage. METHODS Twenty-five interviewees from seven major health insurance companies were selected for a qualitative study in 2007. Using a semi-structured interview, three main tasks of the health financing system (revenue collection, risk pooling and purchasing) were investigated. A framework method was applied for the data analysis. RESULTS The results of the study show the following seven major obstacles to universal coverage: unknown insured rate; regressive financing and non-transparent financial flow; fragmented and non-compulsory system; non-scientifically designed benefit package; non-health-oriented and expensive payment system; uncontrolled demands; and administrative deficiency. A long-term systematic plan is required to address the above problems.

Gatekeeping versus direct-access when patient information matters

We develop a principal-agent model in which the health authority acts as a principal for both a patient and a general practitioner (GP). The goal of the paper is to weigh the merits of gatekeeping versus non-gatekeeping approaches to health care when patient self-health information and patient pressure on GPs to provide referrals for specialized care are considered. We find that, when GPs incentives matter, a non-gatekeeping system is preferable only when (i) patient pressure to refer is sufficiently high and (ii) the quality of the patient's self-health information is neither highly inaccurate (in which case the patient's self-referral will be very inefficient) nor highly accurate (in which case the GP's agency problem will be very costly).

Pediatric Airway Consultation Survey in a Tertiary Care Children's Hospital: An Interobserver Analysis

We conducted a prospective analysis to independently observe the initial opinion of: (1) consulting pediatric residents (postgraduate year 2 [PGY-2]), (2) corresponding considting attending physicians (general pediatric or pediatric emergency medicine) physician, and (3) consulting otolaryngology PGY-2 residents when assessing patients for “noisy breathing.” Each was asked to define the type of noisy breathing present and to formulate a diagnosis based on a limited set of choices. The final diagnosis was determined by a single attending pediatric otolaryngologist (S.E.S.) at the completion of the diagnostic workup. The accuracy for characterization of breath sounds for the pediatric residents, attending pediatricians, and otolaryngology residents were 26.1%, 23.5%, and 98.6%, respectively. The positive predictive values for the determination of diagnosis were 71.6%, 69.4%, and 76.6%, respectively. These findings indicate that pediatric residents and attending pediatricians may be deficient in their ability to characterize the breath sounds commonly seen inpatients with noisy breathing. Further education of pediatricians may lead to a more accurate diagnostic evaluation of a child with noisy breathing.

Differences in referral rates to specialised health care from four primary health care models in Klaipeda, Lithuania

Background

Lithuanian primary health care (PHC) is undergoing changes from the systems prevalent under the Soviet Union, which ensured free access to specialised health care. Currently four different PHC models work in parallel, which offers the opportunity to study their respective effect on referral rates. Our aim was to investigate whether there were differences in referrals rates from different Lithuanian PHC models in Klaipeda after adjustment for co-morbidity.

Methods

The population listed with 18 PHC practices serving inhabitants in Klaipeda city and region (250 070 inhabitants). Four PHC models: rural state-owned family medicine practices, urban privately owned family medicine practices, state-owned polyclinics and privately owned polyclinics. Information on listed patients and referrals during 2005 from each PHC practice in Klaipeda was obtained from the Lithuanian State Sickness Fund database. The database records included information on age, gender, PHC model, referrals and ICD 10 diagnoses. The Johns Hopkins ACG Case-Mix system was used to study co-morbidity. Referral rates from different PHC models were studied using Poisson regression models.

Results

Patients listed with rural state-owned family medicine practices had a significantly lower referral rate to specialised health care than those in the other three PHC models. An increasing co-morbidity level correlated with a higher physician- to self-referral ratio.

Conclusion

Family medicine practices located in rural-, but not in urban areas had significantly lower referral rates to specialised health care. It could not be established whether this was due to organisation, training of physicians or financing, but suggests there is room for improving primary health care in urban areas. Patient's place of residence and co morbidity level were the most important factors for referral rate. We also found that gatekeeping had an effect on the referral pattern with respect to co-morbidity level, so that those with a physician referral were more likely to have had higher co-morbidity.

A cost analysis of the Iowa Medicaid primary care case management program

OBJECTIVE

To determine the cost savings attributable to the implementation and expansion of a primary care case management (PCCM) program on Medicaid costs per member in Iowa from 1989 to 1997.

DATA SOURCES

Medicaid administrative data from Iowa aggregated at the county level.

STUDY DESIGN

Longitudinal analysis of costs per member per month, analyzed by category of medical expense using weighted least squares. We compared the actual costs with the expected costs (in the absence of the PCCM program) to estimate cost savings attributable to the PCCM program.

PRINCIPAL FINDINGS

We estimated that the PCCM program was associated with a savings of US dollars 66 million to the state of Iowa over the study period. Medicaid expenses were 3.8 percent less than what they would have been in the absence of the PCCM program. Effects of the PCCM program appeared to grow stronger over time. Use of the PCCM program was associated with increases in outpatient care and pharmaceutical expenses, but a decrease in hospital and physician expenses.

CONCLUSIONS

Use of a Medicaid PCCM program was associated with substantial aggregate cost savings over an 8-year period, and this effect became stronger over time. Cost reductions appear to have been mediated by substituting outpatient care for inpatient care.

Economic efficiency of gate-keeping compared with fee for service plans: a Swiss example

STUDY OBJECTIVE

The impact of isolated gate-keeping on health care costs remains unclear. The aim of this study was to assess to what extent lower costs in a gate-keeping plan compared with a fee for service plan were attributable to more efficient resource management, or explained by risk selection.

DESIGN

Year 2000 costs to the Swiss statutory sick funds and potentially relevant covariates were assessed retrospectively from beneficiaries participating in an observational study, their primary care physicians, and insurance companies. To adjust for case mix, two-part regression models of health care costs were fitted, consisting of logistic models of any costs occurring, and of generalised linear models of the amount of costs in persons with non-zero costs. Complementary data sources were used to identify selection effects.

SETTING

A gate-keeping plan introduced in 1997 and a fee for service plan, in Aarau, Switzerland.

PARTICIPANTS

Of each plan, 905 randomly selected adult beneficiaries were invited. The overall participation rate was 39%, but was unevenly distributed between plans.

MAIN RESULTS

The characteristics of gate-keeping and fee for service beneficiaries were largely similar. Unadjusted total costs per person were Sw fr 231 (8%) lower in the gate-keeping group. After multivariate adjustment, the estimated cost savings achieved by replacing fee for service based health insurance with gate-keeping in the source population amounted to Sw fr 403-517 (15%-19%) per person. Some selection effects were detected but did not substantially influence this result. An impact of non-detected selection effects cannot be ruled out.

CONCLUSIONS

This study hints at substantial cost savings through gate-keeping that are not attributable to mere risk selection.

The appropriateness of gatekeeping in the provision of reproductive health care for adolescents in Lithuania:the general practice perspective

Background

Adolescents' consultation of primary health care services remains problematic despite their accessibility. The reproductive health service seeking behavior of adolescents is the object of much research but little is known about how this behavior is influenced by the gatekeeping system. This study aimed to explore general practitioners' perceptions of the appropriateness of gatekeeping in adolescent reproductive health care.

Methods

Twenty in-depth interviews regarding factors affecting adolescent reproductive health care were carried out on a diverse sample of general practitioners and analyzed using grounded theory.

Results

The analysis identified several factors that shaped GPs' negative attitude to gatekeeping in adolescent reproductive health care. Its appropriateness in this field was questionable due to a lack of willingness on the part of GPs to provide reproductive health services for teenagers, their insufficient training, inadequately equipped surgeries and low perceived support for reproductive health service provision.

Conclusion

Since factors for improving adolescent reproductive health concern not only physicians but also the health system and policy levels, complex measures should be designed to overcome these barriers. Discussion of a flexible model of gatekeeping, encompassing both co-ordination of care provided by GPs and the possibility of patients' self-referral, should be included in the political agenda. Adolescents tend to under-use rather than over-use reproductive health services and every effort should be made to facilitate the accessibility of such services.

Information asymmetry, insurance, and the decision to hospitalize

We analyze the problem of second-best optimal health insurance in the context of a model in which patients and doctors must decide not only on an aggregate quantity of health services to use in treating various kinds of illness, but also have a choice between different kinds of providers (in particular, outpatient services rendered by primary-care physicians or inpatient services provided by hospital-based specialists). We consider well-informed patients' choices of provider when they have conventional insurance so they only pay part of the cost of their health services, as well as the equilibrium strategies of doctors and patients when there is patient-provider asymmetry; in the latter case we also analyze a managed-care insurance setup under which doctors are paid by capitation. We find that under certain plausible conditions, second-best optimal managed-care plans with supply-side incentives dominate second-best optimal conventional plans that rely on cost control through demand-side cost sharing.

Health expenditures for privately insured adults enrolled in managed care gatekeeping vs indemnity plans

OBJECTIVES

We assessed the ability of managed care gatekeeping strategies (i.e., requiring a designated primary care provider to authorize referrals) to control health care costs in the mid-1990s.

METHODS

We analyzed expenditure data from 8195 privately insured adults sampled in the nationally representative 1996 Medical Expenditure Panel Survey. Managed care gatekeeping plan enrollees included those in health maintenance organizations and other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees.

RESULTS

In 1996, total per capita annual health expenditures for adult gatekeeping enrollees were about $50 less than those of indemnity enrollees, primarily owing to lower out-of-pocket expenditures. After multivariate adjustment, mean per capita expenditures were approximately 6% lower for gatekeeping enrollees than for indemnity enrollees.

CONCLUSIONS

In the private sector, gatekeeping strategies resulted in modest cost savings over indemnity plans.

Physician conceptions of responsibility to individual patients and distributive justice in health care

PURPOSE

Physicians' values may be shifting under managed care, but there have been no empirical data to support this claim. We describe physician conceptions of responsibility to individual patients and distributive justice in health care, and explore whether these values are associated with type of managed care practice and professional satisfaction.

METHODS

We mailed a questionnaire to 500 primary care physicians from 80 out-patient clinics in 11 managed care organizations (MCOs) who were participating in 4 studies designed to improve the quality of depression care in primary care.

RESULTS

We received 414 responses (response rate 83%). Twenty-eight percent of physicians strongly agreed that their main responsibility was to the individual patient rather than to society (strong sense of responsibility to individual patients). Physicians with a strong sense of responsibility to individual patients were older (43% of physicians older than 50 years reported a strong sense of responsibility to individual patients, compared with 26% of physicians aged 36 to 50 years, and 21% of physicians younger than 35 years, P = .009) and tended to practice in network- rather than staff-model MCOs (33% of physicians in network-model MCOs reported a strong sense of responsibility to individual patients compared with 24% in staff-model MCOs, P = .077). Scores on a scale measuring egalitarian conceptions of distributive justice within the health care system were similar for physicians regardless of whether they reported a strong sense of responsibility to individual patients. When we controlled for physician and practice characteristics, physicians with a strong sense of responsibility to individual patients and physicians with higher scores on an egalitarian scale were more likely to be very satisfied overall with their practices (adjusted odds ratio [AOR] = 2.23, 95% confidence interval [CI], 1.11-4.49, and AOR = 1.18, 95% CI, 1.09-1.29, respectively).

CONCLUSIONS

Physicians with a strong sense of responsibility to individual patients are older and less likely to practice in staff-model MCOs. Stronger commitment to an egalitarian health care system and a strong sense of responsibility to individual patients are independently associated with greater practice satisfaction among physicians. The impact of these values on patient care should be a priority for future research and the subject of professional education and debate.

Contribution of primary care to health systems and health

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Does gatekeeping control costs for privately insured children? Findings from the 1996 medical expenditure panel survey

OBJECTIVE

Gatekeeping requirements were widely adopted by health insurers in an attempt to control costs in the mid-1990s, but empirical evidence demonstrating decreased health expenditures for children enrolled in such plans is lacking.

METHODS

We analyzed data from 3254 children with private health insurance sampled in the 1996 Medical Expenditure Panel Survey (MEPS) to compare total per capita health expenditures among gatekeeping versus indemnity plan enrollees. This sample represents 40.4 million privately insured American children. Total expenditures were defined as payments from all sources, including third-party and out-of-pocket payments, but excluding administrative costs. MEPS data are based on information provided by patients, health care providers, and hospitals. Gatekeeping plans included all children enrolled in health maintenance organizations or other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees.

RESULTS

Mean total per capita annual expenditures for children in gatekeeping versus indemnity plans differed by <1% (887 dollars vs 881 dollars, respectively). Third-party payments by gatekeeping plans on behalf of their beneficiaries were 636 dollars versus 595 dollars by indemnity plans. Out-of-pocket payments were on average 62 dollars less for gatekeeping enrollees than for indemnity enrollees. After multivariate adjustment, mean per capita expenditures were approximately 4% lower for gatekeeping enrollees than for indemnity enrollees.

CONCLUSION

In 1996, total per capita annual health expenditures for children in gatekeeping plans were approximately 8 dollars less than for those in indemnity plans. These data indicate that gatekeeping is not an effective cost-containment method for children.

Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study

OBJECTIVES

The specialty referral process is one of the chief targets of managed care constraints on ambulatory medical decision-making. This study examines the influence of gatekeeping arrangements and capitated primary care physician (PCP) payment on the specialty referral process in primary care settings.

RESEARCH DESIGN

Primary care practice-based study of referred and nonreferred office visits.

SUBJECTS

The study comprised 14,709 visits made by privately insured, nonelderly patients who were seen by 139 primary care physicians in 80 practices located in 31 states.

MEASURES

Visits were grouped by health plan type: gatekeeping with capitated PCP payment; gatekeeping with fee-for-service PCP payment; no gatekeeping. Dependent measures included the proportion of visits referred, characteristics of referrals, and physician coordination activities.

RESULTS

The percentages of office visits resulting in a referral were similar between the two gatekeeping groups and higher than the no gatekeeping group. Patients in plans with capitated PCP payment were more likely to be referred for discretionary indications than those in nongatekeeping plans (15.5% v 9.9%, P < 0.05). The frequency of referring physician coordination activities did not vary by health plan type. The proportion of patients in gatekeeping health plans within a practice was directly related to employing staff as referral coordinators, allowing nurses to refer without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages.

CONCLUSION

The specialty referral process for privately insured nonelderly patients enrolled in managed health plans is generally similar, regardless of the presence of gatekeeping arrangements and capitated PCP payment. An increase in the number of discretionary referrals among patients in plans with capitated PCP payment provides support for exploring strategies that encourage PCPs to manage in their entirety conditions that straddle the boundaries between primary and specialty care. In response to increasing numbers of patients enrolled in managed health plans with gatekeeping arrangements, physicians appear to modify the structure of their practices to facilitate access to and coordination of referrals.

Managed care, access to specialists, and outcomes among primary care patients with pain

OBJECTIVE

To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain.

DATA SOURCES/STUDY SETTING

Patient, physician, and office manager questionnaires collected in the Seattle area in 1996-1997, plus data abstracted from patient records and health plans.

STUDY DESIGN

A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle.

DATA COLLECTION

Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines.

PRINCIPAL FINDINGS

A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians.

CONCLUSIONS

Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.

Utilization management: issues, effects, and future prospects

Utilization management encompasses a diverse set of activities designed to influence the use of health care services and thereby constrain health care resource consumption. Utilization management, which has become one of the most widely used cost-containment approaches, has engendered debate and controversy. Physicians have been outspoken critics of utilization management because it has limited their clinical autonomy and has contributed to an intolerable administrative burden. Insurance carriers, managed care plans, and third-party payers have defended the use of utilization management as an imperfect-but necessary-practice that is needed to reduce consumption of unnecessary or inappropriate health care services. This review examines the operation and effects of three widely used utilization management procedures: prospective utilization review, case management, and physician gatekeeping programs. In addition, it explores the future role of utilization management in the health care system and outlines a set of principles that we believe should be used to guide the development of utilization management strategies in the future.

Gatekeeping: a challenge in the management of primary care physicians

Assesses the degree of self-reported implementation of gatekeeping in clinical practice, and gains insight into primary care physicians' attitudes toward gatekeeping and their perceptions of necessary conditions for implementation of gatekeeping in daily practice. A self-administered questionnaire was mailed to a national sample of 800 primary care physicians in Israel, with a response rate of 86 per cent. Multivariate analysis indicated that sick fund affiliation was the main predictor of self-reported implementation of gatekeeping, while specialty training predicted primary care physicians' attitude toward this role. Close communication with specialists, continuous medical education, and management support of physician decisions were identified by respondents as being important conditions for gatekeeping. Discusses strategies to gain the cooperation of primary care physicians, which is necessary for implementing an effective gatekeeping system.

Medical care expenditures under gatekeeper and point-of-service arrangements

OBJECTIVE

To compare expenditures for medical care in a closed-panel gatekeeper HMO and an open-panel point-of-service (POS) plan that share the same provider network.

DATA SOURCE/STUDY SETTING

The two study HMOs are distinct product lines of a single managed care organization; both plans are commercial products. We used administrative data files from the study plans for 1994-95 to assess differences in total medical care expenditures and spending for five categories of services: physician services, inpatient hospital services, outpatient hospital services, prescription drugs, and other services.

STUDY DESIGN

Multivariate analyses were based on the two-part model of the demand for medical care. The dependent variables in these models were expenditures in each of the five categories of services, and the independent variables were indicator variables for plan type and visit copayments, prescription drug copayment, distance to the nearest primary care physician (PCP), demographic characteristics, chronic conditions, area characteristics, and entry/exit indicator variables.

PRINCIPAL FINDINGS

Total expenditures for medical care ranged from equal in both plans to 7 percent higher in the gatekeeper HMO (p < .10), depending on the copayments for physician visits. Expenditures were not higher in the POS plan for any of the five categories of services. These findings were robust to a wide range of sensitivity analyses.

CONCLUSIONS

Direct patient access to specialists in POS plans does not necessarily result in higher medical care expenditures. When POS enrollees are required to choose PCPs, patient cost sharing, physician financial incentives, and utilization review may control expenditures without constraining direct patient access to providers.

Leaving gatekeeping behind--effects of opening access to specialists for adults in a health maintenance organization

BACKGROUND

Gatekeeping refers to the prior approval of referrals to specialists by a primary care physician. Although many health plans view gatekeeping as an essential tool for controlling costs and coordinating care, many patients and physicians object to it.

METHODS

On April 1, 1998, Harvard Vanguard Medical Associates, a large, multispecialty, capitated group practice previously known as Harvard Community Health Plan, eliminated a gatekeeping system that had been in place for over 25 years. We determined the effects of opening access to specialists on visits to primary care physicians and specialists by adults. In randomly selected cohorts of 10,000 members each, we analyzed visits during 6-month periods for the 3 years before and 18 months after gatekeeping was eliminated.

RESULTS

Adults visited a primary care physician an average of 1.21 times and 1.19 times per six-month period before and after the elimination of gatekeeping, respectively (P=0.05); the average number of visits to a specialist was 0.78 per six-month period both before and after its elimination (P=0.35). There was little change in the percentage of visits to specialists included in the analysis as a proportion of all visits (39.1 percent before the elimination of gatekeeping and 39.5 percent afterward). The percentage of first visits to specialists as a proportion of all visits to specialists included in the analysis increased from 24.7 to 28.2 percent (P<0.001). There were small increases in the numbers of visits to orthopedists and physical or occupational therapists. The proportion of visits to specialists for low back pain that were new consultations increased from 26.6 to 32.9 percent (P=0.01).

CONCLUSIONS

In a capitated, multispecialty group practice, we found little evidence of substantial changes in the use of specialty services by adults in the first 18 months after the elimination of gatekeeping.

Switching to gatekeeping: changes in expenditures and utilization for children

BACKGROUND

Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children.

OBJECTIVE

To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions.

DESIGN

We followed a cohort of 1839 children who either voluntarily switched to a gatekeeping plan or remained in an indemnity plan from 1991 through 1994. Study participants were children of employees of a large hospital. The gatekeeping plan was virtually identical to the previous indemnity plan except for lower monthly employee contribution and the requirement for a primary care physician to preapprove subspecialty referrals. We determined the likelihood of a household containing a child with a chronic condition enrolling in the gatekeeping plan, as well as mean annual total, subspecialty, and primary care expenditures and utilization for all children and children with chronic conditions.

RESULTS

Households switching to gatekeeping were less likely to have children with chronic illness (8% vs 15%). Total and subspecialty expenditures for all children decreased more in the gatekeeping group (53% and 59%, respectively) than in the indemnity group (11% and 6%, respectively). For children with chronic conditions, mean visits to subspecialists decreased 57% in the gatekeeping group but increased 31% in the indemnity group. Mean visits to primary care physicians decreased 23% in the gatekeeping group compared with 13% in indemnity group.

CONCLUSION

Parents of children with a chronic condition were much less likely than other parents to switch to a gatekeeping plan. Switching to gatekeeping was associated with reduced visits to specialists but did not increase the involvement of primary care physicians in the management of children with chronic conditions. The implications of these findings for the health of children are unknown.

Affective disorders in children and adolescents: addressing unmet need in primary care settings

Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, owing to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve 1) more systematic implementation of programs that offer coverage for uninsured children; 2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders; and 3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluation of their impacts.

Is general practice effective? A systematic literature review

OBJECTIVE

To find evidence of the effectiveness of physicians working in primary care.

DESIGN

Systematic literature search in the Medline and Cochrane databases.

MATERIAL

Out of 7223 titles found in the search, 45 studies, comparing, from different aspects, primary care with specialist care, were extracted.

MAIN OUTCOME MEASURES

Health indicators, health care costs, quality of health care.

RESULTS

Primary care contributed to improved public health, as expressed through different health parameters, and a lower utilisation of medical care leading to lower costs. Physicians working in primary care, in comparison with other specialists, took care of many diseases without loss of quality and often at lower cost. The organisation of primary care was important in respect of reimbursement by capitation, more group practices, higher personal continuity, and having generalists as primary care physicians.

CONCLUSIONS

To compare the effectiveness of primary care and specialist care is a complex task and there are limitations in all studies. However, we have found evidence that increased accessibility to physicians working in primary care contributes to better health and lower total costs in the health care system. It is also clear that studies with evaluation of how to most effectively organise primary care are far too few. There is an extensive need for future research in this area, a suitable task for collaborative research between the Nordic countries.

Evaluation of knee consultations to a referral-only orthopedic clinic in a managed care system

One hundred sixty-five knee consultations to a referral-only orthopedic service over a 2-year period were reviewed to document the gatekeeper diagnosis and initial treatment plan. These data were compared to the orthopedic evaluation. The majority of gatekeeper referral diagnoses were nonspecific or inaccurate. Several misdiagnoses resulted in prolonged patient recovery (delayed quadriceps tendon repair) and reinjury (recurrent instability of unrecognized anterior cruciate ligament-deficient knees). These findings suggest the gatekeeper model may be inadequate to appropriately manage knee disorders.

Expenditures for physician services under alternative models of managed care

This study compares expenditures for physician services in a closed panel gatekeeper health maintenance organization (HMO) and an open panel point of service HMO that share the same physician network. The study uses administrative files of the two study HMOs for 1994-1995 to assess differences in spending for primary care physicians' (PCPs') services, specialists' services, and total physician services. When the copayments for PCP visits and PCP-referred specialist visits were $0, total physician expenditures were 4 percent higher in the gatekeeper HMO than in the point of service plan (p < .05). When the copayments for PCP visits and PCP-referred specialist visits were $10, total physician expenditures ranged from equal in both HMOs to 7 percent higher in the gatekeeper HMO (p < .01), depending on the copayment for self-referred visits. Expenditures for specialists' services were not higher in the point of service plan. The authors conclude that direct patient access to specialists does not necessarily result in higher physician or specialist expenditures in HMOs.

Effects of primary care coordination on public hospital patients

OBJECTIVE

To evaluate the effect of primary care coordination on utilization rates and satisfaction with care among public hospital patients.

DESIGN

Prospective randomized gatekeeper intervention, with 1-year follow-up.

SETTING

The Adult General Medical Clinic at San Francisco General Hospital, a university-affiliated public hospital.

PATIENTS

We studied 2,293 established patients of 28 primary care physicians.

INTERVENTION

Patients were randomized based on their primary care physician's main clinic day. The 1,121 patients in the intervention group (Ambulatory Patient-Physician Relationship Organized to Achieve Coordinated Healthcare [APPROACH] group) required primary care physician approval to receive specialty and emergency department (ED) services; 1,172 patients in the control group did not.

MEASUREMENTS AND MAIN RESULTS

Changes in outpatient, ED, and inpatient utilization were measured for APPROACH and control groups over the 1-year observation period, and the differences in the changes between groups were calculated to estimate the effect of the intervention. Acceptability of the gatekeeping model was determined via patient satisfaction surveys.

RESULTS

Over the 1-year observation period, APPROACH patients decreased their specialty use by 0.57 visits per year more than control patients did ( P =.04; 95% confidence interval [CI] -1.05 to -0.01). While APPROACH patients increased their primary care use by 0.27 visits per year more than control patients, this difference was not statistically significant (P =.14; 95% CI, -0.11 to 0.66). Changes in low-acuity ED care were similar between the two groups (0. 06 visits per year more in APPROACH group than control group, P =. 42; 95% CI, -0.09 to 0.22). APPROACH patients decreased yearly hospitalizations by 0.14 visits per year more than control patients (P =.02; 95% CI, -0.26 to -0.03). Changes in patient satisfaction with care, perceived access to specialists, and use of out-of-network services between the 2 groups were similar.

CONCLUSIONS

A primary care model of health delivery in a public hospital that utilized a gatekeeping strategy decreased outpatient specialty and hospitalization rates and was acceptable to patients.

Recognition of patient referral desires in an academic managed care plan frequency, determinants, and outcomes

OBJECTIVE

To determine the frequency and determinants of provider nonrecognition of patients' desires for specialist referral.

DESIGN

Prospective study.

SETTING

Internal medicine clinic in an academic medical center providing primary care to patients enrolled in a managed care plan.

PARTICIPANTS

Twelve faculty internists serving as primary care providers (PCPs) for 856 patient visits.

MEASUREMENTS AND MAIN RESULTS

Patients were given previsit and postvisit questionnaires asking about referral desire and visit satisfaction. Providers, blinded to patients' referral desire, were asked after the visit whether a referral was discussed, who initiated the referral discussion, and whether the referral was indicated. Providers failed to discuss referral with 27% of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significant variability in provider recognition of patient referral desire. Recognition is defined as the provider indicating that a referral was discussed when the patient marked a definite or possible desire for referral. Provider recognition improved significantly (P <.05), when the patient had more than one referral desire, if the patient or a family member was a health care worker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P <.05) to initiate a referral discussion when they had seen the PCP previously and had more than one referral desire. Of patient-initiated referral requests, 14% were considered "not indicated" by PCPs. Satisfaction with care did not differ in patients with a referral desire that were referred and those that were nor referred.

CONCLUSIONS

These PCPs frequently failed to explicitly recognize patients' referral desires. Patients were more likely to initiate discussions of a referral desire when they saw their usual PCP and had more than a single referral desire.

[Analysis of the claims in a specialist primary care center]

OBJECTIVE

To analyze the written claims attended at a specialists unit of a Primary Health Care Center in Nou Barris, Barcelona.

DESIGN

Evaluative observational study.

SETTING

Health Care District of Nou Barris, with a population of 170,849. Period of study covers claims attended between 1-6-1996 to 31-12-1998.

PARTICIPANTS

220 claims registered at a specialist unit of a primary health care center.

MEASUREMENTS

Claimer's age and gender, heath care net of origin, claim's motive, claimed person or service and health care activity. Statistical analyses performed included descriptive techniques and Khi-square (chi 2) tests (alpha = 0.05).

RESULTS

Cumulative incidence of claims was 4.03 per 10,000 person-year in 1996, 4.70 in 1997 and 5.88 in 1998 (p = 0.0128). 220 claims were analyzed, 53.1% of them came from women. Mean age was 51.12 +/- 15.8 years. 60% of claims came from people using the traditional health care net, and 40% from reformed health care net. Mean time of response was 12.3 +/- 12.7 days. Ophthalmology was the most claimed service (18.64%), followed by "the system" (13.64%), and "the center" (13.64%). 64% of claims pointed to specialists, and don't adjusted with their health care activity (p = 0.0001). Relative risk of being claimed at the specialists unit was 2.91, compared to the rest of the primary health care centers of Nou Barris in 1998.

CONCLUSIONS

Health care user's claims become useful to detect some difficult aspects. However, improvements in the methodology of their evaluation are needed.

Gatekeeping and referral of children and adolescents to specialty care

OBJECTIVE

In this study we examined how gatekeeping arrangements influence referrals to specialty care for children and adolescents in private and Medicaid insurance plans.

DESIGN/PARTICIPANTS

We conducted a prospective study of office visits (n = 27 104) made to 142 pediatricians in 94 practices distributed throughout 36 states in a national primary care practice-based research network. During 10 practice-days, physicians and patients completed questionnaires on referred patients, while office staff kept logs of all visits. Physicians used medical records to complete questionnaires for a subset of patients 3 months after their referral was made.

RESULTS

Gatekeeping arrangements were common among children and adolescents with private (57.8%) and Medicaid (43.3%) insurance. Patients in gatekeeping plans were more likely to be referred with private (3. 16% vs 1.85% visits referred) and Medicaid (5.39% vs 3.73%) financing. Increased parental requests for specialty care among gatekeeping patients did not explain the increased referral rate. Physicians' reasons for making the referral were similar between the two groups. Physicians were less likely to schedule an appointment or communicate with the specialist for referred patients in gatekeeping plans. However, rates of physician awareness that a specialist visit occurred and specialist communication back to pediatricians did not differ between the two groups 3 months after the referrals were made.

CONCLUSIONS

Gatekeeping arrangements are common among insured children and adolescents in the United States. Our study suggests that gatekeeping arrangements increase referrals from pediatricians' offices to specialty care and compromise some aspects of coordination.

Treating depression in staff-model versus network-model managed care organizations

OBJECTIVE

To compare primary care providers' depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations.

DESIGN

Survey of primary care providers' depression-related practices in 1996.

SETTING AND PARTICIPANTS

We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care.

MEASUREMENTS AND MAIN RESULTS

We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment.

CONCLUSIONS

Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs.

Entry into primary care and continuity: the effects of access

OBJECTIVES

This study examined the relationship between access and use of primary care physicians as sources of first contact and continuity with the medical system.

METHODS

Data from the 1987 National Medical expenditure Survey were used to examine the effects of access on use of primary care physicians as sources of first contact for new episodes of care (by logistic regression) and as sources of continuity for all ambulatory visits (by multi-variate linear regression).

RESULTS

No after-hours care, longer office waits, and longer travel times reduced the chances of a first-contact visit with a primary care physician for acute health problems. Longer appointment waits, no insurance, and no after-hours care were associated with lower levels of continuity. Generalists provided more first-contact care than specialists acting as primary care physicians, largely because of their more accessible practices.

CONCLUSIONS

These data provide support for the linkage between access and care seeking with primary care physicians.

Patterns and determinants of multiple provider use in patients with acute low back pain

OBJECTIVE

To describe the patterns of provider use associated with an acute episode of nonspecific low back pain and their impact on cost.

METHODS

The analysis is based on a prospective cohort study of patients with acute low back pain followed until they recovered completely or to 6 months. Patients were followed after an initial visit to one of four provider types: private primary care physician, chiropractor, orthopedic surgeon, or HMO primary care physician. Follow-up interviews were conducted at baseline, 2, 4, 8, 12, and 24 weeks; 1,580 (97%) of the participants completed the 6-month follow-up.

MAIN RESULTS

Seventy-nine percent of patients saw only the initial provider who began their care for low back pain. Logistic regression revealed that duration of pain prior to initial visit, sciatica, higher Roland disability score, days to functional recovery, interval to complete recovery, referral by initial provider, disk attribution, satisfaction, and the type of index provider were significantly (p < .05) associated with seeking care from multiple provider types. Age, race, gender, and education were not significant. The adjusted proportions of multiple provider type use were 14% (95% confidence interval [CI] 11%, 17%) for the private primary care provider stratum; 19% (95% CI 16%, 23%) for the chiropractic stratum; 30% (95% CI 23%, 37%) for the orthopedic stratum; and 9% (95% CI 5%, 14%) for the HMO primary care physician stratum. Cost of seeing only the index provider was $439 (95% CI $404, $475), and cost of seeing multiple provider types was $1,137 (95% CI $1,064, $1,211) based on the adjusted model.

CONCLUSIONS

Use of multiple provider types, is associated with several factors, one of which is the initial provider type. The cost of such use is significant.

Health care expenditures after introduction of a gatekeeper and a global budget in a Swiss health insurance plan

STUDY OBJECTIVES

To assess whether the introduction of "managed care" (capitated budget and utilisation control by general practitioners) in a Swiss health insurance plan caused a selective disenrolment of plan members, and whether it achieved its goal of reducing health care expenditures.

DESIGN

Controlled before-after analysis of health insurance claims.

SETTING

Health insurance plan of the University of Geneva, Switzerland, which introduced managed care at the end of 1992, and comparison plan, which reimbursed health care expenditures without setting a budget or controlling access.

PARTICIPANTS

Analysis of self selection: university plan members who accepted (3993) or refused (659) transfer to managed care. Analysis of change in expenditures: cohorts of persons continuously enrolled in the university (1575) and comparison (3384) plans in 1992 and 1993.

MAIN RESULTS

During 1992, the year before the transformation of the university plan, persons who refused managed care had generated 35% higher expenditures than those who accepted managed care (p < 0.001). Between 1992 and 1993, expenditures per member decreased by 9% in the university cohort and increased by 11% in the comparison cohort (p = 0.004). Technical procedures (laboratory tests, physical therapy, drugs) decreased most in the university plan. No impact on hospital admissions was detected.

CONCLUSIONS

Introduction of gatekeeping and budget management by physicians caused a favourable self selection process for the university plan. In addition, the managed care plan achieved a substantial decrease in overall health care expenditures in its first year of operation, chiefly by reducing outlays for technical procedures.