Lloyd M. Krieger, M.D., M.B.A.

The "gatekeeper" model for controlling health care utilization is inherently flawed, argues this physician, who says substituting a more flexible system could save money as well as improving health care.

Lloyd M. Krieger, M.D., M.B.A.

See also: Trying Out Alternatives to the 'Gatekeeper' System

Managed care holds the promise of providing better-quality health care to patients while at the same time reducing costs to the individual, to the employers who pay for the bulk of the care and to the nation as a whole. To some extent, managed care has lived up to that promise. In 1994, for the first time in more than a decade, there was a net decrease in the amount that employers paid for their employees' health care. The decrease was due to the higher percentage of employees enrolled in managed care plans. Unfortunately, managed care has fallen short of its full potential as a means of improving patient care and creating cost savings. The reason is that true managed care is actually very hard to find in this country. Instead, most Americans are enrolled in what can best be called "gatekeeper care."

Let's review the gatekeeper model as it is most widely practiced in the independent practice association-, group- and network-model managed care settings. Patients enter the system through a primary care physician. This doctor serves as a gatekeeper, regulating whether and when specialty consultation and treatment are available to them. If a referral is made, it is to a specialist who has a contract with, or is a member of, that particular organization. Prenegotiated discounts and fewer overall referrals lead to savings. After the treatments are finished, there is continuity of care as the patient continues to be followed by his or her primary care doctor.

Management by checklist

The distinction between true managed care and gatekeeper care is revealed at the referral step. Under the current gatekeeper system, the organization provides incentives to the primary care physician not to refer patients to expensive specialists. Often this takes the form of "risk sharing," whereby the primary care physician earns less income with the more referrals or treatments he or she provides to patients. Sometimes the primary care physician must seek approval from the managed care organization prior to offering referral or treatment. The permission-granter might be another physician who serves as medical director of the organization. Often, the physician must win approval from an administrator or a nurse who uses a checklist as the basis for the decision. The system is stacked with negative and positive incentives, all aimed at the gatekeeper, and all designed to keep the gate closed.

When cheaper is useless

These incentives can have bizarre results. A colleague of mine is a neurosurgeon who participates as a provider in many managed care plans. He often receives managed care referrals that have been inappropriately delayed or poorly diagnosed or treated. For example, he notes several occasions when patients saw their primary care doctor with back pain suspicious for herniated disc. The gatekeepers were compensated under a risk-sharing scheme. Accordingly, they attempted to diagnose the back pain with a CT scan, which costs one-third as much as an MRI scan. Unfortunately, a CT is useless in this type of case. An MRI is essential. The patients wound up seeing the neurosurgeon anyway, and getting MRIs. But along the way the system created a delay — to receive an inappropriate diagnostic procedure. The delay allowed time for the disease to progress, and this made the patient that much more likely to require expensive surgery. Colleagues in many specialties describe analogous experiences.

Time for redefinition

The problem with the gatekeeper model is that it is designed to limit, rather than truly integrate, patient care. The lack of integration results in delayed or inappropriate referrals. It causes inappropriate tests or procedures to be done prior to, or instead of, referrals. This, in turn, leads to progression of disease, and worse and more expensive outcomes.

While the current system provides continuity of care in that the patient eventually returns to point A, the trip to point B is riddled with potholes. The layers of the organization are integrated only in the sense that there is systemic difficulty in providing expensive referrals and treat- ments. This leads to inefficiency and other problems in patient care, and dissatisfaction among patients and physicians.

It is time to redefine the role of the gatekeeper. The gatekeeper should be charged with integrating the organization, rather than simply limiting access to its next step.

Changing the system

There are several concrete steps that will accomplish this task. The key is for primary care physicians and specialists to communicate before, during and after referrals. For example, a "specialist clearinghouse" should be developed within the managed care organization. When a gatekeeper encounters a patient who may or may not require specialist treatment, the primary care doctor should be able easily to speak with a specialist regarding the problem. He or she will call upon the appropriate member of the specialist clearinghouse.

The specialist will educate the primary care doctor about whether to refer the patient upward, or what tests ought to be performed in order to decide whether to make the referral. If appropriate, the specialist will describe what basic treatments the primary care doctor can provide prior to, or instead of, referral.

Specialists in the organization might have "office hours" during which they are available through the specialist clearinghouse to answer primary care doctors' questions. For specialists, one requirement for membership in the organization might be to provide two or three hours per week for this purpose. Specialists also might provide formal continuing education programs for primary care physicians aimed at describing new trends in their fields, and things that primary care doctors should look out for in their offices when evaluating a patient for a possible diagnostic workup or referral.

Why would busy specialists submit to office-hours requirements and create continuing education requirements? Recruiting specialists will become easier as time goes on and more specialists bear risk under capitation contracts of their own. They will be grateful for the opportunity to help in making sure that patients are referred to them in an appropriate, timely fashion — before there is advancement of disease and the need for more expensive interventions. In the meantime, the organization can create financial incentives to encourage specialist participation.

Penalizing pound-foolishness

The next step toward making the gatekeeper into an integrator of health care is to create incentives to have appropriate referrals to specialists, rather than simply penalizing the gatekeepers for any referrals. If a disease is allowed to progress because the gatekeeper delayed referral, he or she should face financial penalties. Returning to my previous example of herniated disc, if a gatekeeper sees a patient with a possible herniated disc and is uncertain about the next diagnostic step, his or her first action should be to call a neurosurgeon through the specialist clearinghouse. If the gatekeeper skips this step and orders an inappropriate CT scan instead of the necessary MRI, the costs of both the proper and improper studies might be deducted from the doctor's capitation or bonus payment. Likewise, gatekeepers who make timely, appropriate referrals should be provided with financial rewards. Patient outcome data and specialist feedback can aid in the determination of timeliness and appropriateness of referrals.

The current gatekeeper model of managed care is flawed. The structure is designed almost exclusively to delay or block referrals to specialists. This made sense when there was no control of expensive specialist access or diagnostic procedures. But managed care is maturing and offers potentials beyond cost savings from simple limitation of access.

Short run vs. long

Monolithic limitation saves money in the short run, but provides neither the best nor the least expensive care in the long run. Primary care doctors, specialists and patients chafe under its rigid constraints. The solution is to make the gatekeeper the integrator of patient care. This will require improved communication between primary care doctors and specialists. It will require improved access among the layers of the organization such that gatekeepers and specialists can confer quickly, easily and often. It will require the creation of incentives for specialists to participate in these discussions and for gatekeepers to take advantage of the opportunity.

When gatekeepers become the integrators of patient care, the system will run more smoothly. Patients will get better care. Provider morale will improve. In the long run, there will be cost savings. Better care at lower cost.

Wasn't that the promise of managed care in the first place?

The author is a resident in the integrated plastic surgery program at the University of California at Los Angeles Medical Center. His articles about financial issues in health care have appeared in The New York Times, The Los Angeles Times and Barron's.

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