Primary Care Physicians Should Be Coordinators, Not Gatekeepers

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 specialist...

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Bibliographic Details
Published in:JAMA : the journal of the American Medical Association 1999-06, Vol.281 (21), p.2045-2049
Main Authors: Bodenheimer, Thomas, Lo, Bernard, Casalino, Lawrence
Format: Article
Language:English
Subjects:
Biological and medical sciences
Case Management
Continuity of Patient Care - organization & administration
Cost Control
Health Care Costs
Humans
Medical sciences
Medicine
Models, Organizational
Physician's Role
Physicians
Physicians, Family
Primary care
Public health. Hygiene
Public health. Hygiene-occupational medicine
Quality Assurance, Health Care
Referral and Consultation - economics
Referral and Consultation - organization & administration
Roles
Specialization
Teaching. Deontology. Ethics. Legislation
United States
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Summary: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.
ISSN:0098-7484
1538-3598
DOI:10.1001/jama.281.21.2045