August 2003

Grant Results

National Program

Changes in Health Care Financing and Organization

SUMMARY

In 1995–1997, David Blumenthal, M.D., Ph.D., and researchers at Massachusetts General Hospital, Boston, evaluated the impact of a major component of managed care — the use of a primary care physician as a gatekeeper to authorize all health services of HMO members.

Researchers collected health care claims data from the two years before and the two years after patients switched from a traditional indemnity plan without gatekeepers to an HMO. Researchers also conducted self-administered surveys of both patients and physicians.

This project was part of the Robert Wood Johnson Foundation (RWJF) national program Changes in Health Care Financing and Organization (HCFO) (for more information see Grant Results).

Key Findings
Researchers reported the following findings in a Findings Brief available at the HCFO Web site.

  • Primarily as a result of reduced use of specialists, gatekeeping resulted in lower costs during the first year. However, costs rose during the second year as patients became familiar with administrative requirements for obtaining specialist care. Second year costs were just below indemnity plan levels.
  • The gatekeeping requirement appeared to improve continuity of care through the advice and oversight of specialty care provided by the primary care physician.
  • HMO enrollees were less positive than indemnity plan subscribers about:
    • Information provided by their primary care physician.
    • The thoroughness of physical examinations.
    • Their physician's personal interest, attention and amount of time with them.
  • Although physicians were positive about cost control in the gatekeeping system, they felt that gatekeeping did not yield as much quality of care and satisfaction as the traditional indemnity plan did.
  • Gatekeeping did not result in a significant increase in preventive health care measures such as number of Pap tests, mammograms and other screening procedures.

Funding
RWJF provided a $490,559 grant for the project between January 1995 and December 1997.

 See Grant Detail & Contact Information
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THE PROJECT

Gatekeeping is a feature of managed health care by which an enrollee's primary care physician, acting as a utilization manager, makes decisions about the need for specialty providers and services. Taking advantage of a natural experiment that occurred at Massachusetts General Hospital in Boston in 1993 when employees had an opportunity to switch from a traditional indemnity health insurance plan without gatekeepers to a health maintenance organization (HMO), researchers studied:

  • How gatekeeping affects health care cost, access and quality.
  • Patient and provider satisfaction within a gatekeeping system.
  • Factors (economic, demographic, etc.) associated with the choice of a health plan that requires a gatekeeper.

Researchers collected health care claims data from the two years before and the two years after the switch to the HMO. They also conducted self-administered surveys of both patients and physicians.

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FINDINGS

Researchers reported the following findings in a Findings Brief available on the HCFO Web site:

  • Primarily as a result of reduced use of specialists, gatekeeping resulted in lower costs during the first year. However, costs rose during the second year as patients became familiar with administrative requirements for obtaining specialist care. Second year costs were just below indemnity plan levels.
  • The gatekeeping requirement appeared to improve continuity of care through the advice and oversight of specialty care provided by the primary care physician.
  • HMO enrollees were less positive than indemnity plan subscribers about:
    • Information provided by their primary care physician.
    • The thoroughness of physical examinations.
    • Their physician's personal interest, attention and amount of time with them.
    • Communications with physicians outside of scheduled appointments.
    • In regard to the use of specialists, HMO enrollees expressed dissatisfaction with the difficulty of obtaining referrals and with specialist-related billing problems.
  • Although physicians were positive about cost control in the gatekeeping system, they felt that gatekeeping did not yield as much quality of care and satisfaction as the traditional indemnity plan did. When cost and quality were combined, 72 percent of physicians rated gatekeeping as equal to or better than the indemnity plan. Physicians giving higher ratings tended to have been in practice for fewer years, to be generalists rather than specialists and to have fewer patients enrolled in an HMO.
  • Gatekeeping did not result in a significant increase in preventive health care measures such as number of Pap tests, mammograms and other screening procedures.
  • Higher income employees were less likely to switch to the HMO, suggesting that flexibility and choice are important for those who can afford an indemnity plan.

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GRANT DETAILS & CONTACT INFORMATION

Project

Effect of Physician Gatekeepers on Health Care Cost, Access and Quality

Grantee

General Hospital Corporation - Massachusetts General Hospital (Boston,  MA)

  • Amount: $ 490,559
    Dates: January 1995 to December 1997
    ID#:  024831

Contact

David Blumenthal, M.D., Ph.D.
(617) 726-5212
dblumenthal@partners.org

Web Site

http://www.hcfo.net

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Halm EA, Causino N and Blumenthal D. "Is Gatekeeping Better than Traditional Care? A Survey of Physicians' Attitudes." Journal of the American Medical Association, 278(20): 1677–1681, 1997. Abstract available online.

Ferris TG, Perrin JM, Manganello JA, Chang Y, Causino N and Blumenthal D. "Switching to Gatekeeping: Changes in Expenditures and Utilization for Children." Pediatrics, 108(2): 283–290, 2001. Abstract available online.

Ferris TG, Chang Y, Blumenthal D and Pearson SD. "Leaving Gatekeeping Behind — Effects of Opening Access to Specialists for Adults in a Health Maintenance Organization." New England Journal of Medicine, 345(18): 1312–1317, 2001. Abstract available online.

Ferris TG, Chang Y, Perrin JM, Blumenthal D and Pearson SD. "Effects of Removing Gatekeeping on Specialist Utilization by Children in a Health Maintenance Organization." Archives of Pediatrics and Adolescent Medicine, 156(6): 574–579, 2002. Abstract available online.

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Report prepared by: Mary Geisz
Reviewed by: Robert Crum
Reviewed by: Molly McKaughan
Program Officer: Nancy L. Barrand

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