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PubMed2000

Will German patients accept their family physician as a gatekeeper?

OBJECTIVE: Looking to the experience in the United States with managed care and the possible introduction of gatekeeping in the near future in Germany, we performed a population-based survey to examine preferences for future gatekeeping arrangements. DESIGN: Cross-sectional telephone survey. SETTING: Four health districts in Thuringia (formerly East Germany) and Lower Saxony (formerly West Germany). PARTICIPANTS: Out of a random sample of 644 adults in the 4 districts, 415 persons (64.4%) took part in the survey. MEASUREMENTS AND MAIN RESULTS: Using multiple logistic regression, we analyzed associations between preferences for gatekeeping arrangements and patient satisfaction, insurance status, and sociodemographic characteristics. Seventy-four percent of respondents valued first-contact care, especially older people (odds ratio [OR], 4.3; 95% confidence interval [95% CI], 2.0 to 9.3), people who were very satisfied with the relationship with their family physician (OR, 2.7; 95% CI, 1.6 to 4.8) and members of sickness funds in contrast to privately insured persons (OR, 2.4; 95% CI, 1.2 to 5.2). The family physician's influence in coordinating the use of specialist services was appreciated by 86%, more often by members of sickness funds (OR, 5.9; 95% CI, 2.4 to 14. 3), people who were very satisfied with their doctor's professional competence (OR, 3.2; 95% CI, 1.6 to 6.3) and older persons (OR, 2.9; 95% CI, 1.1 to 7.7). CONCLUSIONS: A vast majority of the German population would accept their family physician as entry point and as coordinator of all other health services. Since patient satisfaction, among other reasons, strongly influenced preferences for gatekeeper arrangements, family physicians themselves may be able to promote primary care health services.

Adult↗
PubMed2006

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.

Adolescent↗
PubMed2000

Visits to primary care physicians and to specialists under gatekeeper and point-of-service arrangements.

OBJECTIVE: To assess utilization of ambulatory visits to primary care physicians (PCPs) and to specialists in 2 different managed care models: a closed panel gatekeeper health maintenance organization (HMO) and an open panel point-of-service HMO. STUDY DESIGN: Retrospective study of patients enrolled in a single managed care organization with 2 distinct product lines: a gatekeeper HMO and a point-of-service HMO. Both plans shared the same physician network. PATIENTS AND METHODS: The study sample included 16,192 working-age members of the gatekeeper HMO and 36,819 working-age members of the point-of-service HMO. We estimated the number of PCP and specialist visits using negative binomial regression models and predicted the number of visits per year for each person under each HMO type and copayment option. RESULTS: There were more annual visits to PCPs and a greater number of total physician visits in the gatekeeper HMO than in the point-of-service plan. However, we did not observe higher rates of specialist visits in the point-of-service HMO. CONCLUSION: We found no evidence that direct patient access to specialists leads to higher rates of specialty visits in plans with modest cost-sharing arrangements.

Adolescent↗
PubMed2003

Gatekeeping and children's health care costs.

In the 1990's, primary care gatekeeping became a hallmark of managed care and a major model of health care delivery. Proponents claimed that gatekeeping--requiring that primary care providers preauthorize specialty visits--could control costs and improve coordination of care. However, much of this potential has remained unrealized, and managed care organizations are beginning to loosen these restrictions. This Issue Brief adds to the growing literature on the ineffectiveness of gatekeeping in controlling costs in pediatric care. The following study focuses on privately insured children, and analyzes the impact of gatekeeping on their health care expenditures.

Child↗
PubMed2005

Targeting the gatekeeper residue in phosphoinositide 3-kinases.

A single residue in the ATP binding pocket of protein kinases-termed the gatekeeper-has been shown to control sensitivity to a wide range of small molecule inhibitors (Chem. Biol.2004, 11, 691; Chem. Biol.1999, 6, 671). Kinases that possess a small side chain at this position (Thr, Ala, or Gly) are readily targeted by structurally diverse classes of inhibitors, whereas kinases that possess a larger residue at this position are broadly resistant. Recently, lipid kinases of the phosphoinositide 3-kinase (PI3-K) family have become the focus of intense research interest as potential drug targets (Chem. Biol.2003, 10, 207; Curr. Opin. Pharmacol.2003, 3, 426). In this study, we identify the residue that corresponds structurally to the gatekeeper in PI3-Ks, and explore its importance in controlling enzyme activity and small molecule sensitivity. Isoleucine 848 of p110alpha was mutated to alanine and glycine, but the mutated kinase was found to have severely impaired enzymatic activity. A structural bioinformatic comparison of this kinase with its yeast orthologs identified second site mutations that rescued the enzymatic activity of the I848A kinase. To probe the dimensions of the gatekeeper pocket, a focused panel of analogs of the PI3-K inhibitor LY294002 was synthesized and its activity against gatekeeper mutated and wild-type p110alpha was assessed.

Animals↗
PubMed1992

Seeking approval for research access: the gatekeeper's role in facilitating a study of the care of the relinquishing mother.

While undertaking a study of midwives' care of mothers relinquishing a baby for adoption, the search for permission for access provided valuable insights into the role and functioning of the 'gatekeepers', who included a range of nursing/midwifery personnel and others. The benefits and positive aspects of this process are discussed. The variability of the response to the request for permission for research access gives insight into the gatekeepers' decision-making process. The functioning of research ethics committees is shown to be unpredictable. The gatekeepers' comments are related to the comments made by mothers in an early stage of the study. The way in which the gatekeepers utilize their own individual experience is crucial to their decisions regarding permitting research access. This experience may take the form of personal experience, occupational experience or experience of research.

Adoption↗
PubMed2001

Effect of ethnicity on denial of authorization for emergency department care by managed care gatekeepers.

OBJECTIVE: After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital. METHODS: A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO. RESULTS: African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94). CONCLUSIONS: African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.

Adolescent↗
PubMed1995

The wizard and the gatekeeper: of castles and contracts.

The wizards and the gatekeepers were unhappy. There were many reasons for their unhappiness. They worked hard but felt that too much was being demanded of them. The poorly people's charter was resulting in unrealistic expectations, and changes in the apprenticeship for wizards were putting great strain on their mentors. The wizards enjoyed their work less and less, and it was getting difficult to find new gatekeepers. On the other hand, the way the system worked meant that there had to be plenty of goblins and the number of scrolls that had to be filled in was rising sharply. The wizards and gatekeepers tried to point out ways to improve things that would ensure that poorly people were better treated, but there was no easy solution. With the ominous sign that the recruitment of wizards and gatekeepers was becoming more difficult, an answer was needed--and soon.

Family Practice↗
PubMed1977

The mental health gatekeeper role: a paradigm for conceptual pretest. Proposal for a preliminary test of potential effectiveness.

Two of the major themes in the community psychiatry movement have been the employment of new and different types of persons in service roles and the maintenance of clients in the community, whenever possible, with avoidance of institutionalisation. A logical outcome of the combination of these two themes has been an increasing interest in the role of persons with fixed social roles within the community as gatekeepers for actual direct service or appropriate referrals into the mental health service system. Police, clergy and bartenders are among the social roles that have received serious consideration and, in some cases, actual use as points of entry and actual service. Careful analysis of the likely requirements of the gatekeeper role will show, however, that many existing social roles that appear fertile ground for the mental health gatekeeper function are in fact lacking in certain features necessary to such a role. This paper presents five criteria considered important or essential to any conclusion that a given role should be seriously considered for the gatekeeper function. These criteria may serve for a shortcut prior to the investment of money and time and may thus have false and expensive steps in our enthusiastic but often hasty search for innovation.

Community Mental Health Services↗
PubMed1985

The internist as gatekeeper. Preparing the general internist for a new role.

To reduce health care costs, some third-party payers have enlisted primary care physicians as gatekeepers to medical care. In gatekeeper systems, primary care physicians must approve all care provided to their patients. This approval is a condition of payment for the service, with the usual exception of true emergencies. The gatekeeper approach, sometimes called the case-manager plan, extends the responsibility of primary care physicians from coordination to control of medical care. However, for the plan to stimulate cost-effective medical care, it must overcome obstacles that threaten its ability to save money and provide high-quality medical care. If internists are to serve as gatekeepers, then medical educators must ensure that the necessary attitudes, skills, and knowledge are taught to students of internal medicine.

Cost Control↗
PubMed1991

Rollover effects in gatekeeper programs: cushioning the impact of restricted choice.

Public and private medical care plans that restrict the beneficiary's choice of providers have experienced rapid growth in the past decade as a means to contain costs and coordinate care. Such plans have been criticized for engendering beneficiary dissatisfaction and potentially impeding access to necessary care. Some of the objections to primary care "gatekeeping" may be diminished by recruiting the physician who served previously as the beneficiary's "usual source of care" to assume the role of formal gatekeeper. This study examines how persons whose gatekeepers were their regular source of care before plan implementation differed in their use and satisfaction from persons required to change their regular source of care. Our findings indicate that satisfaction was significantly higher among individuals who experienced no change in usual source of care. These individuals also tended to be less likely to use the emergency department as a source of care. Although the data are from Medicaid managed care programs, the findings may also be applicable to private sector point-of-service plans that adopt the primary care gatekeeper model.

Ambulatory Care↗
PubMed1991

Gatekeeper effects on patterns of physician use.

The impact of primary care gatekeeping on selected patterns of physician use was examined among Medicaid beneficiaries in two demonstration programs. The evidence indicates that beneficiaries enrolled with gatekeepers were significantly less likely to see specialists when compared with unenrolled beneficiaries in comparison groups. Primary care visits increased to offset these reductions only when gatekeepers were paid on a fee-for-service basis. Increased overall reliance on primary care physicians as opposed to specialists was also observed in the gatekeeper programs. Findings also indicate that enrolled beneficiaries received care from fewer sources than they had prior to enrollment. Although these changes in patterns of use have the potential to assure access to a more stable and structured system of care, the clinical and long-term economic consequences of such changes remain unknown.

Adult↗
PubMed2002

The gatekeeper in vision care. An analysis of the co-ordination of professional services in The Netherlands.

Data from a national survey were used to explore the position of ophthalmologists, general practitioners, orthoptists, optometrists and opticians in the domain of vision care services. Options for organising the gatekeeper function were analysed. This was done on the basis of six cases that the five key occupations considered as their overlapping areas. Nearly all respondents reported to be consulted by patients with the given complaints, indicating rather unclear boundaries between the professions. Further, the opinions indicated preference for a medical gatekeeper (ophthalmologist, GP) rather than a non-medical one (optometrist). Lack of agreement on suggested gatekeeper options suggest other options to consider, like regional networks of GPs, ophthalmologists, orthoptists and optometrists who share the responsibility for a specified client population. At present, such innovative arrangements are being introduced. GPs and optometrists could share the responsibility for gate-keeping and for referring patients to more specialised services.

Attitude of Health Personnel↗
PubMed2002

'Carer and gatekeeper' - conflicting demands in nurses' experiences of telephone advisory services.

'Carer and gatekeeper' - conflicting demands in nurses' experiences of telephone advisory services Millions of calls are made to the telephone advisory services in primary health care in Sweden. The patients seem happy with the advice and counselling they receive, but little has been written about nurses' experiences of performing telephone advisory services. Yet, the nurses are expected to be patient, sensitive and have a broad knowledge of medicine, nursing and pedagogy. The aim of this study was to describe how nurses experience the patient encounter when performing telephone advisory services. A strategic sample of five nurses were interviewed and asked to describe how they experienced the central aspects of the patient encounter by telephone. The transcribed interviews were analysed by the Empirical Phenomenological Psychological method. The nurses' experience of the patient encounter when performing telephone advisory services can be characterized in terms of the conflicting demands of being both carer and gatekeeper. The constituents of these conflicting demands were: reading between the lines while pressed for time; educating patients for self-care while fearful of misinterpreting the situation; encountering patients' satisfaction and dissatisfaction. The conflicting demands of being both professional carer and gatekeeper caused stress among the nurses. The organization of the telephone advisory services seems to hinder high-quality care.

Attitude of Health Personnel↗
PubMed2003

Introduction of the patient-list system in general practice. Changes in Norwegian physicians' perception of their gatekeeper role.

OBJECTIVE: To explore whether the patient-list system, recently introduced in general practice, has influenced general practitioners' (GPs') self-perception as gatekeepers. DESIGN: Structured focus group interviews with GPs and a short self-administered questionnaire. SETTING: Primary care within the public health care system in Norway. Group interviews were conducted 6 months to 1 year after the patient-list system was introduced in June, 2001. SUBJECTS: 81 GPs attending tutorial groups or specialists' continuous education groups. OUTCOME MEASURES: GPs' experience with the reform as stated in 11 group discussions, recorded, transcribed and systematically analysed through coding and extracting of the informants' statements. The questionnaire provided background information about each participant. RESULTS: The doctors generally perceived themselves as less concerned with the gatekeeper role under the new system. They felt it more important to provide better services and keep patients satisfied. The practitioners explained this shift using three contextual factors: increased and more visible competition, higher expectations from the patients and more responsibility assigned to the GP. CONCLUSION: GPs in Norway have experienced a shift in power in the physician-patient relationship favouring the patient. The GP's consciousness of the gatekeeper role has diminished. We question whether the new system lessens the incentive to consider resource use in decision-making.

Adult↗
PubMed2001

Suicide prevention in Aboriginal communities: application of community gatekeeper training.

OBJECTIVE: Concern over the high rate of suicide among Aboriginal people on the south coast of NSW led to the development of a project aimed at preventing youth suicide in the Aboriginal communities of the Shoalhaven. This paper describes the development, implementation and evaluation of the project. METHOD: Following extensive consultation with the Aboriginal community, a range of culturally appropriate interventions were developed. The main focus was a series of community gatekeeper training workshops, which aimed to increase the potential of members of the Aboriginal community to identify and support people at risk of suicide and to facilitate their access to helping services. RESULTS: Evaluation of the workshops demonstrated an increase in participants' knowledge about suicide, greater confidence in identification of people who are suicidal, and high levels of intentions to provide help. Attitudes, subjective norms and barriers predicted intentions to help. CONCLUSIONS: The project indicated community members could be successfully trained in the recognition of individuals at risk of suicidal behaviour. Gatekeepers' attitudes and perceived barriers to helping predicted intentions to help those in need. There is a need for longer-term follow-up to assess the extent to which new knowledge and skills are used in practice. IMPLICATIONS: Suicide awareness and skills training have been demonstrated to be an effective early intervention strategy. Gatekeeper training empowers Aboriginal communities and is generally accepted. There is demand for such programs outside the Shoalhaven. The project has a methodological framework that can be easily adapted by other communities.

Adult↗
PubMed2001

Primary care physicians in Israel: self-perception of their role in the healthcare system and policy makers' and patients' perception of them as gatekeepers.

BACKGROUND: The rapidly increasing costs of healthcare pose a major challenge to many governments, particularly in developed countries. Health policy makers in some Western European countries have adopted the policy of a strong primary healthcare system, partly due to their recognition of the value of primary care medicine as a means to restrain costs while maintaining the quality and equity of healthcare services. In these countries there is a growing comprehension that the role of the family physician should be central, with responsibility for assessing the overall health needs of the individual, for coordination of medical care and, as the primary caregiver, for most of the individual's medical problems in the framework of the family and the community. OBJECTIVES: To describe primary care physicians in Israel from their own perception, health policy makers' opinion on the role PCPs should play, and patients' view on their role as gatekeepers. METHODS: The study was based on three research tools: a) a questionnaire mailed to a representative sample of all PCPs employed by the four sick funds in Israel in 1997, b) in-depth semi-structured interviews with key professionals and policy makers in the healthcare system, and c) a national telephone survey of a random representative sample of patients conducted in 1997. RESULTS: PCPs were asked to rank the importance of 12 primary functions. A total of 95% considered coordination of all patient care to be a very important function, but only 43% thought that weighing economic considerations in patient management is important, and 30.6% thought that 24 hour responsibility for patients is important. Also, 60% of PCPs have undergone specialty training and 94% thought that this training is essential. With regard to the policy makers, most preferred highly trained PCPs (board-certified family physicians, pediatricians and internists) and believed they should play a central role in the healthcare system, acting as coordinators, highly accessible and able to weigh cost considerations. Yet, half opposed a full gatekeeper model. They also felt that the general population has lost faith in PCPs, and that most have a low status and do not have adequate training. Regarding the patients' viewpoint, 40% preferred that the PCP function as their "personal physician" coordinating all aspects of their care and fully in charge of their referrals; 30% preferred self-referral to sub-specialists, and 19% preferred their PCP to coordinate their care but wanted to be able to refer themselves to specialists. CONCLUSIONS: In order to maintain high quality primary care, it is important that all PCPs have board certification. In addition, PCP training systems should emphasize preventive medicine, health promotion, health economy, and cost-effectiveness issues. Efforts should be made to render PCPs a central role in the healthcare system by gradually implementing the elements of the gatekeeper model through incentives rather than regulations.

Adult↗
PubMed2002

[What does it feel like for a physician to be a gatekeeper?].

BACKGROUND: Doctors increasingly act as gatekeepers. We have studied the effect that this function has on the doctors themselves. MATERIAL AND METHODS: Analysis of 24 questions from large surveys of representative samples of Norwegian doctors in 1993 and 2000. RESULTS: Six out of seven doctors sometimes or often met unrealistic demands from patients. More than one third experienced stress because of patient expectations about help for non-medical problems. Nearly 50% had adjusted medical certificates in order to help the patient. More than 50% sometimes or often gave more weight to patients' wishes than to their own medical judgement. 86% had chosen to come in for work themselves when they would have certified as sick a patient with the same symptoms and working situation. The proportions were significantly smaller among older doctors and doctors with a high level of job satisfaction. INTERPRETATION: The gatekeeper role has important influence on doctors' job satisfaction. A possible generation effect may imply that society will meet problems more often in the future when assigning gatekeeper functions to doctors.

Adult↗