Effects of Removing Gatekeeping on Specialist Utilization by Children in a Health Maintenance Organization

Timothy G. G. Ferris · Yuchiao Chang · James M. Perrin · David Blumenthal · Steven D. Pearson

25 citations0/0 files storedArchives of Pediatrics and Adolescent Medicine

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Healthcare Systems and Technology Healthcare Policy and Management Primary Care and Health Outcomes

Abstract

BACKGROUND: The "gatekeeping" model of access to specialty care has been an essential managed care tool, intended to control costs of care and promote coordination between generalists and specialists. OBJECTIVE: To investigate the impact of removing gatekeeping on specialist utilization. METHODS: A capitated multispecialty group discontinued a gatekeeping system on April 1, 1998. We assessed the overall number and distribution of patient visits to primary care physicians and specialists and initial patient visits to specialists before and after the removal of gatekeeping. We performed focused analyses for specific specialties, children with chronic conditions, and children with specific diagnoses. RESULTS: Elimination of gatekeeping was not associated with changes in the mean number of visits to specialists (0.28 visits per 6 months before and after gatekeeping was removed) or the percentage of all child visits to specialists (11.6% vs 12.1%; 95% confidence interval, 11.3%-11.9% vs 11.8%-12.4%). The proportion of all specialist visits that were initial consultations increased after gatekeeping was removed, from 30.6% (95% CI, 29.4%-31.8%) to 34.8% (95% CI, 33.6%-36.1%). Visits to any specialist by children with chronic conditions increased from 18.6% (95% CI, 17.7%-19.1%) to 19.8% (95% CI, 19.0%-20.7%). New patient visits to specialists by children with chronic conditions as a proportion of all specialist visits increased from 28.1% (95% CI, 25.9%-30.2%) to 32.3% (95% CI, 30.1%-34.5%). CONCLUSIONS: Replacing a gatekeeping system with open access to all specialty physicians in a managed care organization resulted in minimal changes on the utilization of specialists. Visits to specialists by children with chronic conditions increased after the removal of gatekeeping.

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References

1999Resolving the Gatekeeper Conundrum 1989Effect of a gatekeeper plan on health services use and charges: a randomized trial.2001Leaving Gatekeeping Behind — Effects of Opening Access to Specialists for Adults in a Health Maintenance Organization 1999Views of Managed Care — A Survey of Students, Residents, Faculty, and Deans at Medical Schools in the United States 1999Gatekeeping and Referral of Children and Adolescents to Specialty Care

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2006Role of Insurance for Children With Special Health Care Needs: A Synthesis of the Evidence

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