Resolving the Gatekeeper Conundrum

TLDR

Few data exist on how patients perceive primary care physicians as gatekeepers in managed care systems. The study aimed to assess patients' valuation of primary care physicians as first‑contact providers and referral coordinators, their perception of gatekeeping barriers to specialists, and the impact of such barriers on trust and confidence. A cross‑sectional mailed survey of 7,718 managed‑care patients in California collected data on attitudes toward primary care physicians, trust and satisfaction ratings, and perceived referral barriers, and analyzed barriers as predictors of physician ratings. The survey found that 94 % of patients valued primary care physicians as first‑contact providers, 89 % as referral coordinators, 75–91 % preferred initial care from PCPs, 23 % reported interference, and those experiencing referral barriers were 2–3 times more likely to report low trust, confidence, and satisfaction, indicating that gatekeeping policies erode patient confidence.

Abstract

Few data are available regarding how patients view the role of primary care physicians as "gatekeepers" in managed care systems.To determine the extent to which patients value the role of their primary care physicians as first-contact care providers and coordinators of referrals, whether patients perceive that their primary care physicians impede access to specialists, and whether problems in gaining access to specialists are associated with a reduction in patients' trust and confidence in their primary care physicians.Cross-sectional survey mailed in the fall of 1997 to 12707 adult patients who were members of managed care plans and received care from 10 large physician groups in California. The response rate among eligible patients was 71%. A total of 7718 patients (mean age, 66.7 years; 32 % female) were eligible for analysis.Questionnaire items addressed 3 main topics: (1) patient attitudes toward the first-contact and coordinating role of their primary care physicians, (2) patients' ratings of their primary care physicians (trust and confidence in and satisfaction with), and (3) patient perceptions of barriers to specialty referrals. Referral barriers were analyzed as predictors of patients' ratings of their physicians.Almost all patients valued the role of a primary care physician as a source of first-contact care (94%) and coordinator of referrals (89%). Depending on the specific medical problem, 75% to 91% of patients preferred to seek care initially from their primary care physicians rather than specialists. Twenty-three percent reported that their primary care physicians or medical groups interfered with their ability to see specialists. Patients who had difficulty obtaining referrals were more likely to report low trust (adjusted odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2) with their primary care physicians.Patients value the first-contact and coordinating role of primary care physicians. However, managed care policies that emphasize primary care physicians as gatekeepers impeding access to specialists undermine patients' trust and confidence in their primary care physicians.