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PubMedDate not supplied

Managed care? Not without gatekeepers and capitation.

Absolutely essential to truly managed health care are gatekeeping and capitated financial arrangements with providers, says TPF&C's national practice leader for group benefits consulting. He explains why he believes conventional notions of "managed care" are insufficient and how employers can press insurance carriers to accept (not just share) the financial risks of health coverage, as Cigna has done in a new arrangement with Allied-Signal, Inc.

Cost Control↗
PubMed1987

"Gatekeeper technology." Recasting a primary care role.

The gatekeeper approach to the delivery of medical care, while not really a new concept, has a new raison d'être--cost containment. It infuses a new form of authority into the role of primary care physicians while at the same time it brings new challenges of practicing more cost-effective medicine and maintaining quality of care. Primary care physicians can take steps to meet these challenges.

Cost Control↗
PubMed1999

[Medical judgment and legal security. Physicians as gatekeepers in the distribution of public goods].

We wanted to explore general practitioners' discretionary judgments about the eligibility of patients applying for disability pension, and to examine if variations in such judgments are correlated with the physicians' personal values and moral standards. Data were collected by a postal questionnaire, which included two vignettes focusing on whether the "applicant" fulfils the eligibility criteria for disability benefit. Variations in judgments were then analysed in correlation to the GP's view on normative questions concerning the physicians' role as gatekeepers, the disability pension as a source of income, and an indicator of the GP's scepticism to the disability pension. 360 general practitioners from eight different counties in Norway participated. The response rate was 62 per cent. The assessment of the vignettes revealed great variation. Four out of ten general practitioners concluded that the first vignette fulfilled the medical eligibility criteria, while three out of ten came to the opposite conclusion. For the second vignette the results were reversed. For both vignettes, three out of ten were not able to answer "yes" or "no" because of uncertainty. Further, the variation in judgments was correlated with an indicator of the GPs' personal values and moral standards. The stronger expressed disability pension scepticism, the more restrictive interpretation of the medical eligibility criteria. A decision on entitlement to disability pension pertains to the distribution of public goods. The general practitioners' discretionary judgments are crucial in this decision-making. When doctors let their political and moral standards influence their judgment, they act arbitrarily and in conflict with ideals of equal treatment and legal security.

Adult↗
PubMed2001

ABCA1. The gatekeeper for eliminating excess tissue cholesterol.

It is widely believed that HDL functions to transport cholesterol from peripheral cells to the liver by reverse cholesterol transport, a pathway that may protect against atherosclerosis by clearing excess cholesterol from arterial cells. A cellular ATP-binding cassette transporter (ABC) called ABCA1 mediates the first step of reverse cholesterol transport: the transfer of cellular cholesterol and phospholipids to lipid-poor apolipoproteins. Mutations in ABCA1 cause Tangier disease (TD), a severe HDL deficiency syndrome characterized by accumulation of cholesterol in tissue macrophages and prevalent atherosclerosis. Studies of TD heterozygotes revealed that ABCA1 activity is a major determinant of plasma HDL levels and susceptibility to CVD. Drugs that induce ABCA1 in mice increase clearance of cholesterol from tissues and inhibit intestinal absorption of dietary cholesterol. Multiple factors related to lipid metabolism and other processes modulate expression and tissue distribution of ABCA1.Therefore, as the primary gatekeeper for eliminating tissue cholesterol, ABCA1 has a major impact on cellular and whole body cholesterol metabolism and is likely to play an important role in protecting against cardiovascular disease.

ATP Binding Cassette Transporter 1↗
PubMed2006

Principal dental admissions officers: Who are dentistry's gatekeepers?

Little is known about principal dental admissions officers (PDAO) in U.S. dental schools who may be viewed as the gatekeepers to our schools. To address this gap, this study examined the characteristics of PDAOs in U.S. dental schools. A web-based, fifty-five-question survey on the personal and professional characteristics, roles, areas of responsibilities, and areas considered of importance to PDAOs was sent to fifty-six principal dental admissions officers at U.S. dental schools, followed by telephone calls to encourage participation. Thirty-eight PDAOs responded. The typical PDAO was Caucasian, fifty-two years of age, and had been in the position about eight years, earning dollar 80,000 annually. Most supervised one or more employees and spent time working for the school outside the admissions process. Student contact activity considered most important was counseling prospective students, while maintaining health and financial records was considered unimportant. Minority recruitment efforts were considered highly important by a majority of PDAOs. The PDAOs have varied educational backgrounds and positions, but perform functions primarily dedicated to admissions.

Administrative Personnel↗
PubMed1988

Service utilization and psychiatric diagnosis in pediatric primary care: the role of the gatekeeper.

Levels of morbidity in 789 children 7 to 11 years of age attending two primary care pediatric clinics in a health maintenance organization were examined in relation to psychiatric disturbance. Physical morbidity was measured as mean number of illness episodes per year enrolled, based on the child's medical record. Two measures of psychiatric disturbance were compared: the pediatricians' judgment and a detailed assessment using standard psychiatric interviews with parent and child. Children identified by pediatricians as disturbed had more than twice as many physical illness episodes as nonidentified children. Children identified by the standard psychiatric assessment had the same number of physical illness episodes as nondisturbed children. Pediatricians showed high specificity but low sensitivity to mental illness. Their sensitivity in the high user group was double that in the low user group. These results suggest that (1) the association between mental illness and high use may be, in part, the result of the confounding factor of physicians' judgment; (2) in settings where primary care practitioners serve as "gatekeepers" to mental health services, the offset effect of lower medical service use following psychiatric treatment may be partially explained by this; (3) the source of referral must be taken into account when assessing the offset effect in other settings.

Child↗
PubMed1983

And who shall be the gatekeeper? The role of the primary physician in the health care delivery system.

In a speech at the Duke University Medical Center, the author discussed the growing interest in a primary care "gatekeeper" to monitor and/or control patient use of hospital and specialist services. She pointed out that there have been advocates for such a system for over 50 years-partly to assure appropriate levels of care to the entire population, partly to reduce the costs of more expensive specialist care. She went on to discuss the issues inherent in such a concept.

Costs and Cost Analysis↗
PubMed1996

Primary care physicians as gatekeepers in managed care. Primary care physicians' and dermatologists' skills at secondary prevention of skin cancer.

BACKGROUND AND DESIGN: This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. RESULTS: Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. CONCLUSIONS: Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.

Adult↗
PubMed1997

Gatekeepers no more: family practitioners as power brokers and fence wanderers.

The term gatekeeping in the context of primary care is neither controversial nor appropriate; it cannot be used to describe the complex interactions between general practitioners, their patients and the complexities of the evolving health system, euphemistically called health reform. Advocacy has now become paramount if general practice is to survive as a discipline in the face of competing economic forces eroding total patient care.

Conflict of Interest↗
PubMed1997

My brother's gatekeeper.

When doctors launch their own managed care ventures, they soon find that cost control means care control. And in policing their own, they must resort to the techniques used by other health plans--gatekeepers and all.

American Medical Association↗
PubMed1997

Trichoepitheliomas contain somatic mutations in the overexpressed PTCH gene: support for a gatekeeper mechanism in skin tumorigenesis.

The nevoid basal cell carcinoma (Gorlin) syndrome (NBCCS) is an autosomal dominant disorder characterized by multiple developmental defects and cancer susceptibility. NBCCS is caused by mutations in the human homologue (PTCH) of the Drosophila patched gene, a developmental regulator implicated in signaling of hedgehog and smoothened. The PTCH gene was found to contain somatic mutations also in sporadic basal cell carcinomas and medulloblastomas, tumors seen in NBCCS, consistent with PTCH acting as a tumor suppressor. Because basal cell carcinomas have been observed to develop in association with benign trichoepitheliomas (TEs) in the same lesions, patients, and families and may share the same cell of origin, we have analyzed PTCH for mutations and expression in TEs. We report frameshift and in-frame somatic deletions in this gene and a consistent overexpression of PTCH mRNA in TEs. These findings provide the first evidence of a gene mutation in TEs and identify a common pathogenic pathway for histopathologically similar but prognostically distinct skin tumors. Moreover, these results support the presence of a gatekeeper mechanism in multistep skin tumorigenesis exerted by the altered PTCH signaling pathway.

Adult↗
PubMed1997

The medical specialist: information gateway or gatekeeper for the family practitioner.

The medical specialist emerged as a critical gatekeeper in a study of information sources used by family practitioners in New Zealand. Thirty-four practitioners in the Wellington region were interviewed and their responses examined to ascertain the extent to which five criteria influenced their choice of information sources for clinical decision-making. The criteria were availability, searchability, understandability, credibility, and applicability. Of three major information sources investigated (textbooks, colleagues, and medical specialists), textbooks were consulted most frequently but were rated less valuable than colleagues and specialists as a source of information. The medical specialist was identified as the information source that best meets the five criteria. Thus, specialists play an important role in disseminating information to family practitioners. However, female practitioners included in the study were less likely to approach specialists than were their male counterparts. Physicians made little use of medical libraries to support clinical decision-making. The apparent disadvantage of female practitioners in accessing specialists needs to be addressed by professional associations. Medical librarians seeking to improve the access of family practitioners to recent literature should consider the heavy use made of specialists as a source of information.

Adult↗
PubMed1997

[Tracking the gatekeeper gene in the stages of carcinogenesis in the bladder].

Bladder cancers display different forms from superficial to aggressive tumours with muscle invasion. Many studies on this disease have been carried out in order to better understand the molecular mechanisms involved in its progression. Two loci are frequently associated with bladder tumorigenesis. The chromosome 9 lesions seem to be earlier involved in carcinogenesis, and suggest the presence of a tumour suppressor gene, and on the other hand the TP53 gene mutations (17q13.1) are later but take place in tumour progression. These alterations could be used as early diagnosis tool in bladder tumours and orientate the search for the bladder cancer gatekeeper gene(s).

Chromosome Mapping↗
PubMed1998

Report from the front lines: rural Medicaid primary care providers as gatekeepers of rural health service networks.

This study of primary care practitioners in Louisiana's Medicaid managed care program, Community Care, focused on the program's implementation and perceived impact. PCPs were interviewed to assess their perceived responsibilities as gatekeepers and how well they believed the system facilitated or impeded their fulfillment of those responsibilities, to examine issues of access and quality, and to determine their knowledge and use of local referral networks. Findings indicate that although they appreciated the financial stability derived from having a larger patient base and understood their roles well, they were concerned with several facets of the program, including perceived limitations imposed on their medical decision making, an added burden of paperwork, and a lack of both downward and upward communication. They also believed the referral network of available providers for medical and social services to be more limited for their Medicaid patients than for their private patients. Policy implications are discussed.

Attitude of Health Personnel↗
PubMed2026

The effect of dietetic counseling combined with digital tools intervention on hemodynamic markers in Greek adults: The GATEKEEPER Study.

BACKGROUND AND AIM: Hypertension is a leading cardiovascular risk factor with substantial global impact on morbidity, mortality, and healthcare costs. While lifestyle interventions remain central to management, mHealth technologies offer promising adjunctive support, though their clinical effectiveness remains uncertain. This study evaluated whether combining dietetic counseling with digital tools improves hemodynamic markers in adults aged ≥55 years with increased cardiometabolic risk. METHODS AND RESULTS: This 3-month RCT (NCT05031299) included 954 adults with at least one metabolic syndrome risk factor, allocated 1:1:1 to Standard Care (dietetic counseling), Platform (counseling plus web-based platform), or Platform + Devices (counseling plus platform plus wearables). Outcomes included anthropometrics, lifestyle characteristics, blood pressure, pulse pressure, and estimated pulse wave velocity, analyzed using linear mixed-effects models adjusted for age and sex. All groups improved over 3 months. Waist circumference decreased by -6.29, -4.92, and -4.69 cm across Standard Care, Platform, and Platform + Devices groups respectively, and systolic blood pressure declined by -4.84 to -7.15 mmHg across groups. The Platform + Devices group showed greater increases in physical activity (94.62 MET-min/week; 95% CI 66.49 to 122.76) and greater reductions in pulse pressure (-3.90 mmHg; -6.58 to -1.22) versus Standard Care. Weight loss was associated with lower odds of hypertension (OR 0.4; 95% CI 0.2-0.7), greater likelihood of hypertension reversal (OR 3.6; 1.2-10.3), and higher probability of achieving normal pulse pressure (OR 1.8; 1.1-3.1). CONCLUSIONS: Dietary lifestyle intervention improved cardiometabolic outcomes, with limited added benefit from digital tools. Weight loss was the primary driver of hemodynamic improvement.

Aged↗