Study Shows Physician Gatekeeping May Help Lower Costs, But Questions Remain about Physician and Patient Satisfaction

In 1995–1997, David Blumenthal, MD, PhD, 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).

Key Findings

  • Researchers reported the following findings in a Findings Brief available at the HCFO website.

    • 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.