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PubMed1997

[Patient initiative and referral decision of the primary care physician].

Using the German data of the European referral study from primary to secondary care this paper attempts to answer the following questions: which are the specialties GPs refer to, and which referrals were initiated by the patients. According to the study's methodology the gatekeeper function of the GPs or the patient initiative should be described by distinguishing between direct and indirect referrals. A direct referral is defined by a face to face encounter between patient and GP, while an indirect referral requires no such contact. For direct referral the GPs recorded the influence of the patient on their referral decision. In 71 practices (only the western part of the Federal Republic of Germany) 2077 direct and 1665 indirect referrals were documented. Every second direct referral was influenced by the patients. Women had a greater influence than men. An analysis by specialty showed that most of the direct referrals were directed to orthopaedics (14%), surgery (12%) and internal medicine (10%) and most of the indirect referrals to ophthalmology (25%), gynaecology (20%) and dermatology (8%) (64% of all indirect referrals were given to women). These results could be taken as an example how patients take over the responsibility of managing their complaints and illnesses by themselves in a health system with free access to specialist care. The role of the German GP as a gatekeeper and co-ordinator in the health care system turned out to be very limited. In consequence this might result in future problems such as a lack of co-operation, deficiencies in the continuity of medical treatment, over-medication unnecessary parallel investigations and additional costs.

Adolescent↗
PubMed1998

[Consultations in ophthalmological practice. A multi-practice study of referrals to private ophthalmologists in Denmark].

In Denmark the GPs act as gatekeepers for secondary health care services except for ophthalmologists and ear-nose-throat specialists. The aim of this study was to describe consultations and referral patterns to ophthalmologists in private practice in Denmark. Forty-four out of 143 practising ophthalmologists agreed to fill out a short questionnaire on a random sample of their patients. They recorded 1844 consultations. Forty percent of contacts were appointments arranged by the ophthalmologist, 35% were self-referred, 13% were referred by their GP and 12% by others. Cataract, glaucoma and refraction anomalies accounted for 51% of all diagnoses. The distribution of reasons for encounter and diagnoses among self-referred patients and patients referred by their GP does not argue in favour of a change from the present system with free self-referral to a system with gatekeeping by GPs.

Denmark↗
PubMed1998

Audit of populations in general practice: the creation of a national resource for the study of morbidity in Scottish general practice.

STUDY OBJECTIVE: To create a national data resource for studying morbidity in Scottish general practice, complementary to existing information systems and available for management and research purposes at national and local levels. DESIGN: The Department of General Practice, University of Aberdeen has worked since 1988 to collect and analyse computerised information at practice, regional, and national levels by distribution of a floppy disk-based software program, which extracts a predetermined dataset from each general practice computer system. SETTING: Almost 100% of patients in Scotland are registered with a general practitioner. Scotland has a national computer system, General Practice Administration System for Scotland (GPASS), used by over 75% of all Scottish practices. Escalating costs of health care and demographic changes in the national population emphasise the monetary value of the gatekeeper role of general medical practice. General practitioners' increasing involvement in the provision and purchasing of care has raised the importance of the management of populations as well as the care of individual patients. PATIENTS: Collection of major morbidity and prescribing data from up to 2.4 million patients, approximately half the population of Scotland, takes place biannually. A subset of practices (population 282,700 patients; 52 practices) are continuously collecting doctor/patient contact information (symptoms or diagnoses). MAIN RESULTS: The data collected provide information at the level of the individual patient. Morbidity, prescribing, screening, and administrative data can be linked by patient, date or postcode. The sample population studied is representative by age, sex, deprivation, and sparsity (using the postcode) of the national population. Large sub-populations of patients satisfying a selected criteria can be extracted for further study of needs assessment or of epidemiological research. CONCLUSIONS: The gatekeeping role of Scottish general practice and the predominance of GPASS favours standardisation of methods of data capture and the construction of large regional, national, and Continuous Morbidity databases. Analysis by geographical, demographic, and temporal distributions allows the changing patterns of illness and provision of health care to be studied in substantial detail to the benefit of patients, doctors, and the national health service.

Adolescent↗
PubMed1998

The determinants of health expenditure in the OECD countries: a pooled data analysis.

This paper uses international health expenditure and the latest OECD data to investigate the determinants of aggregate health expenditure. The study differs from most previous studies in two principal ways. First, it uses a somewhat larger sample for estimation, with pooled time-series, cross-section data for 22 OECD countries for a 20-year period. Most previous work has used a purely cross-section approach: in this case, the small sample size reduced the statistical reliability of results and limited the number of hypotheses that can be tested simultaneously. Second, and following from this, a more extensive range of hypotheses is tested, with particular emphasis on those relating to the contractual relations between payers, providers and patients. The findings show, for example, that the use of primary care "gatekeepers" seems to result in lower health expenditure and also that the way of remunerating physicians in the ambulatory care sector appears to influence health expenditure; capitation systems tend to lead to lower expenditure than fee-for-service systems.

Cross-Cultural Comparison↗
PubMed2004

[Outcome of interactive training in detection and management skills for schizophrenic outpatient treatment by general practitioners].

THEORETICAL BACKGROUND: Of all outpatients with a diagnosis of schizophrenia, 30-40% refuse a psychiatrist's care. For this group of patients the general practitioner holds a key position for such different tasks as detection of prodromal schizophrenia or early warning signs of relapse and identification of risk variables for deteriorating outcome, gatekeeping (referral to specialists or other services), integration, and counseling of key relatives. Fifty percent of GPs are interested in disease-specific medical education programs. STUDY DESIGN AND METHODS: A control trial examined the changes that participating GPs intended to make in three main topics of the curriculum: (1) changing attitudes (pessimistic outcome expectation, low self-esteem), (2) enhancement of detection skills (prodromal schizophrenia, early warning signs of relapse, and risk factors for poor social and vocational integration), and (3) enhancement of management skills (dosing schemes, motivational interviewing). RESULTS: In the assessment 2 weeks after the training session, we found significant changes in favor of the trained group in detection and management skills and also improved self-confidence of GPs. CONCLUSIONS: Problem-oriented and case-based learning strategies should be preferred to lectures in training programs for psychiatric skills in primary care.

Adult↗
PubMed2003

The role of managed care and financing in medical practices: how does psychiatry differ from other medical fields?

BACKGROUND: The organization and financing of medical practice has experienced substantial changes during the past decade. Today the majority of individuals with private insurance are enrolled in managed care plans and traditional indemnity insurance is only predominant among Medicare enrollees. At the same time that managed care was growing in general, there was also substantial growth in the number of managed care companies specializing in behavioral health care and separating them out ("carved-out") from other medical care. While it is clear that these changes in managed care penetration and financing arrangements have affected physicians and the way they practice medicine, it is less clear whether there has been a differential effect across physician types. METHOD: Data are from the Community Tracking Study (CTS) physician survey, a national survey of active physicians in the United States fielded between August 1998 and November 1999. To be eligible, physicians had to have completed their medical training (which excludes residents, interns, or fellows), be practicing in the contiguous United States, and be providing direct patient care for at least 20h per week. The total number of completed interviews was 12,304, including 566 psychiatrists, 7,217 primary care physicians, and 4,521 other medical or surgical specialists. Consistent with the previous literature, our analysis is primarily descriptive presenting weighted means and odds ratios from multivariate models. RESULTS: Psychiatrists are significantly less likely than primary care physicians or other specialists to agree with the statements that clinical decisions in the interest of their patients do not reduce income. Further, in comparison to primary care physicians, psychiatrists are less likely to agree that it is possible to maintain continuing relationships with patients over time that promote the delivery of high quality care and that they have the freedom to make clinical decisions that meet their patients' needs. In contrast to the perceived impacts on practice, psychiatrists tend to work in practices with a lower dependence on managed care than either other specialists or primary care physicians. Regarding individual physician compensation among non-owners, psychiatrists are less likely than other physicians to have their income adjusted based on individual productivity. CONCLUSIONS: Psychiatrists are more concerned that managed care has a negative impact on patient-provider relationships than other physicians; however, based on the available measures of financing and organization, psychiatrists are less dependent on managed care. This may suggest that other aspects of managed care, such as pre-authorization and gatekeeping, that disproportionately affect specialists are driving psychiatrists' perceptions of the patient-provider relationship.

Adult↗
PubMed2004

Impact of national health care systems on patient evaluations of general practice in Europe.

OBJECTIVE: To examine associations between patient evaluations of general practice and characteristics of national health care systems. METHODS: International comparative study in 17 countries, using international patient survey data (n= 25052) and data-bases for health care system characteristics. Dependent variable was patients' evaluation of general practice care. Five independent factors were examined: GP density, physician density, fee for service reimbursement, gatekeeper role, and first-contact role. RESULTS: None of the associations were statistically significant. CONCLUSIONS: Patients were highly satisfied with general practice in different national health care systems. Descriptive tables on international variations may lead to misleading conclusions.

Europe↗
PubMed2003

Changing the nature of physician referral relationships in the US: the impact of managed care.

Prior to the era of managed care in the US, health care delivery was managed by the professional activities of physicians. Managed care replaces management by profession with bureaucratic management structures and oversight, such as utilization review and gatekeeping (required referrals to specialty care). Practically, this means that physicians cannot use the professional relationships that typified practice under fee-for-service medicine, potentially changing not only what physicians do (e.g., order test or not, refer or not), but also how they do what they do. In this paper I look at just one of the changes brought about by managed care: contractual arrangements that require primary care providers to refer patients to a closed panel of specialist physicians. Through an in-depth case study of 45 primary care providers' in the USA who face restricted specialist panels for their managed care patients, but not for their fee-for-service patients, I investigate how the practice of referring is changed by this requirement. First, I use interview data to describe primary care providers general preferences for referral consultants, as well as their views of the referral process and potential barriers in it. Next I present data from all referrals over a four-week period to analyze the extent of referral relationships in actual referrals. Finally, I conclude by discussing some ways that managed care entities can facilitate rather than diminish referral relationships among physicians.

Fee-for-Service Plans↗
PubMed2001

System effects of the Kansas Mental Health Reform Act of 1991.

This paper analyzes the impact of the Kansas Mental Health Reform Act on client outcomes. The Act is of general interest because it reflects a trial of greater accountability without major changes in financial incentives. It made Community Mental Health Centers [CMHCs] gatekeepers that were accountable for services for adults with severe and persistent mental illnesses. The Act sought reductions in hospitalizations rates, expanded use of community support services, and increased independent living. The structure of the Act and Client Status Reports allow rigorous examination of these outcomes. The number of clients served increased significantly. Even though hospital days fell by 23%, there is no clear evidence that the Act itself reduced hospital days per client. The proportion of community support program clients residing independently rose significantly; the proportion participating meaningfully in the labor market fell. The goals of the Act were realized overall, but the performance of CMHCs varied considerably.

Activities of Daily Living↗
PubMed2000

[Continuing education, motivation for cost control, a Swiss experiment].

The article reviews the prospective, controlled experience of the introduction of a physician network service (health maintenance organisation 5000 insured persons). There was a reduction of cost (26%-33%) compared with the control group, without loss of quality. This reduction still holds good after four years. Risk selection explains only a small part of the reduction in cost. The only interventions consisted of gatekeeping plus continuing medical education (CME). Diagnosis and financial data were not available and profiling was not used to control the experience. CME was provided by a quality circle once a week. In these meetings, the subjective and objective features particular to outpatient medicine were addressed.

Cost Control↗
PubMed2006

General practice as seen through the eyes of general practice trainees: a qualitative study.

OBJECTIVE: To explore the perceptions of general practice trainees regarding their discipline and to compare these spontaneously expressed views with recently proposed definitions of general practice. MATERIAL AND METHODS: A qualitative focus-group study was conducted in one Belgian and two French medical schools. Twenty-eight trainees took part (16 from Belgium and 12 from France). The transcripts were analysed by the immersion crystallization method. RESULTS: The participants in this study seemed prepared to take on the many responsibilities outlined in various definitions of general practice, but feared personal commitment to accessibility and continuous care. Being skilled clinicians and patients' advocates formed their "raison d'être" in the healthcare system. They were reluctant to act as gatekeepers within the system, a role that might jeopardize their advocacy function for their patients. They mentioned the lack of appeal of entrepreneurship aspect of practice. Participants reported that training settings typically offer traditional models of practice, which sometimes led them to feel estranged from a profession that they felt needs reorganization. CONCLUSIONS: Participants' descriptions generally coincided with official definitions of general practitioners' tasks, except for practice management and gate-keeping aspects. They were willing to accept the burden of general practice as long as responsibility could be shared and as long as there was freedom for flexible progress along a modern career track.

Adult↗
PubMed2002

Attitudes to family practice registration programmes. Survey of Korean and Norwegian family doctors.

BACKGROUND: In order to save money and improve continuity, many countries plan to introduce registration programmes and capitation. OBJECTIVE: The aim of this study was to explore family doctors' attitudes towards such programmes. METHODS: Random samples of board-certified Korean family doctors (n = 205) and Norwegian general practice specialists (n = 257) were included in a postal survey using a structured questionnaire with visual analogue scales. Main outcome measures were demographic characteristics, practice types, workload, level of agreement with 10 statements and explanatory variables for the principal attitude towards a registration programme (regression analyses). RESULTS: Overall response rate was 79%. Nineteen per cent [95% confidence interval (CI) 14-23%] of Norwegian and 96% (95% CI 93-99%) of Korean doctors were solo practitioners. Korean doctors reported 388 (95% CI 359-418) consultations per week and Norwegian doctors 83 (95% CI 80-87). Satisfaction with their present organization was lower in Korea (50%, 95% CI 46-53%) than in Norway (71%, 95% CI 68-74%). Korean doctors were more in favour of a registration programme (70%, 95% CI 66-73%) than Norwegian doctors (57%, 95% CI 53-61%). Main explanatory variables for being in favour of a registration programme were increased continuity (beta 0.495, P < 0.001) and dissatisfaction with the present system (beta -0.212, P < 0.001). In Korea, the prospect of more comprehensive care (beta 0.440, P < 0.001) and a positive attitude towards gatekeeping (beta 0.193, P < 0.001) were strong predictors, while Norwegian doctors favour a registration programme if it will not increase their workload (beta -0.166, P < 0.01). CONCLUSION: Regardless of nationality, most family doctors favour a registration programme.

Attitude of Health Personnel↗
PubMed2000

When sick patients switch primary care physicians: the impact on AMCs participating in capitation.

Patients facing catastrophic illness often desire choice when selecting specialist physicians and will sometimes request specialists at academic medical centers (AMCs). Under capitated payment systems, community primary care physician (PCP) gatekeepers have an incentive to refer patients to local specialists with whom they regularly collaborate rather than to AMC specialists, who generally are more expensive and with whom they may not have working relationships. As a result of the financial pressures of capitation and the desire to work with familiar specialists, some PCPs in community-based risk-sharing groups are reluctant to refer sick patients in capitated health plans to AMC-affiliated specialists. Forced to choose between their existing primary care relationships and their desired specialists, some patients are terminating their existing primary care relationships to enroll with PCPs affiliated with the AMCs to which they wish to be referred. The authors' observations at their AMC indicate that most of the patients leaving their PCPs in the community do so to gain access to oncology and surgical specialty services. The shifting of sick patients in capitated health plans to AMC-affiliated PCPs creates a financial burden for both AMCs and their affiliated physicians. Health plans and AMCs must cooperate in developing a solution; for example, risk-adjust each risk unit's capitation payment based on the health status and disease burden of its population. The authors propose strategies aimed at enabling patients to have access to AMC tertiary care services while ensuring that the cost of caring for the sickest patients is not borne solely by AMC risk groups. They conclude that it is in the best interests of all concerned to modify the current counterproductive incentives that promote the problems they have described.

Academic Medical Centers↗
PubMed2005

The shifting engines of medicalization.

Social scientists and other analysts have written about medicalization since at least the 1970s. Most of these studies depict the medical profession, interprofessional or organizational contests, or social movements and interest groups as the prime movers toward medicalization. This article contends that changes in medicine in the past two decades are altering the medicalization process. Using several case examples, I argue that three major changes in medical knowledge and organization have engendered an important shift in the engines that drive medicalization: biotechnology (especially the pharmaceutical industry and genetics), consumers, and managed care. Doctors are still gatekeepers for medical treatment, but their role has become more subordinate in the expansion or contraction of medicalization. Medicalization is now more driven by commercial and market interests than by professional claims-makers. The definitional center of medicalization remains constant, but the availability of new pharmaceutical and potential genetic treatments are increasingly drivers for new medical categories. This requires a shift in the sociological focus examining medicalization for the twenty-first century.

Biotechnology↗
PubMed2002

From physician to consumer: the effectiveness of strategies to manage health care utilization.

Many strategies are commonly used to influence physician behavior in managed care organizations. This review examines the effectiveness of three mechanisms to influence physician behavior: financial incentives directed at providers or patients, policies/procedures for managing care, and the selection/education of both providers and patients. The authors reach three conclusions. First, all health care systems use financial incentives, but these mechanisms are shifting away from financial incentives directed at the physician to those directed at the consumer. Second, heavily procedural strategies such as utilization review and gatekeeping show some evidence of effectiveness but are highly unpopular due to their restrictions on physician and patient choice. Third, a future system built on consumer choice is contradicted by mechanisms that rely solely on narrow networks of providers or the education of physicians. If patients become the new locus of decision making in health care, provider-focused mechanisms to influence physician behavior will not disappear but are likely to decline in importance.

Case Management↗
PubMed2006

Collaboration with general practitioners: preferences of medical specialists--a qualitative study.

BACKGROUND: Collaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates medical specialists to initiate and continue participating with GPs in new collaborative care models. The following question is addressed in this study: What motivates medical specialists to initiate and sustain new models for collaborating with GPs? METHODS: We conducted semi-structured interviews with eighteen medical specialists in the province of Groningen, in the North of The Netherlands. The sampling criteria were age, gender, type of hospital in which they were practicing, and specialty. The interviews were recorded, fully transcribed, and analysed by three researchers working independently. The resulting motivational factors were grouped into categories. RESULTS: 'Teaching GPs' and 'regulating patient flow' (referrals) appeared to dominate when the motivational factors were considered. In addition, specialists want to develop relationships with the GPs on a more personal level. Most specialists believe that there is not much they can learn from GPs. 'Lack of time', 'no financial compensation', and 'no support from colleagues' were considered to be the main concerns to establishing collaborative care practices. Additionally, projects were often experienced as too complex and time consuming whereas guidelines were experienced as too restrictive. CONCLUSION: Specialists are particularly interested in collaborating because the GP is the gatekeeper for access to secondary health care resources. Specialists feel that they are able to teach the GPs something, but they do not feel that they have anything to learn from the GPs. With respect to professional expertise, therefore, specialists do not consider GPs as equals. Once personal relationships with the GPs have been established, an informal network with incidental professional contact seems to be sufficient to satisfy the collaborative needs of the specialist. The concerns seem to outweigh any positive motivational forces to developing new models of collaborative practice.

Adult↗
PubMed2001

Physicians, thou shalt ration: the necessary role of bedside rationing in controlling healthcare costs.

Physicians are often asked to be "gatekeepers," determining their patients' access to medical therapies and technologies. At the same time, most physicians have been taught that they should act as patient advocates, pursuing patients' best interests regardless of cost. This paper reviews moral arguments ethicists have made for and against "bedside rationing." It argues that healthcare rationing is appropriate in order to help control healthcare costs, and that rationing decisions made at the bedside by physicians must be part of the rationing system. A system that attempts to control costs by mandating an elaborate set of rules would be burdensome, and many physicians would find ways

Decision Making↗
PubMed1997

Who should manage care? The case for patients.

After establishing that it is essential that health care be rationed in some fashion, the paper examines the arguments for and against clinicians as gatekeepers. It first argues that bedside clinicians do not have the information needed to make allocation decisions. Then it claims that physicians at the bedside can be expected to make the wrong choice for two reasons: their commitment to the Hippocratic ethic forces them to pursue the patient's best interest (even when resources will produce only very marginal benefit and could do much more good elsewhere) and their values will lead them to calculate the net value of treatments incorrectly. Alternative decision makers are considered. It is argued that both groups of physicians and administrators will also make allocations incorrectly and that leaving the allocation decisions to patients themselves is the best approach. Mechanisms for fair and efficient rationing by patients at the societal and individual level are examined.

Administrative Personnel↗