Primary care in the United States: Primary care gatekeeping and referrals: effective filter or failed experiment?

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Abstract
The use of primary care physicians as gatekeepers to specialists and other medical resources—considered to be a managed care innovation in the United States—has proliferated during the past few decades. Its introduction has been accompanied by a government sponsored programme of research into referrals from primary care (box 1). Findings from these studies may offer insights into how the UK's NHS could shape the gatekeeping function of general practitioners. This article discusses the concept of gatekeeping, contrasts the processes of referral to specialists in the United States and the United Kingdom, examines the mechanisms by which gatekeeping influences resource allocation, and discusses the effects of linking gatekeeping with financial incentives and utilisation review. #### Summary points Gatekeeping systems have emerged in countries with scarce medical resources Gatekeepers ensure equity by judiciously matching healthcare services, including specialty referrals, to healthcare needs Gatekeeping alters patients' behaviour, increasing levels of first contact care with primary care physicians, thereby reducing patients' self referrals Patients in US health plans with gatekeeping arrangements are twice as likely to be referred to specialist care as their UK counterparts There is little evidence that gatekeeping has had much effect on patients' referral rates in the United States, a healthcare environment rich in specialists Within modern societies, gatekeepers are positioned between organisations and individuals who wish to use resources within those organisations. Gatekeepers use discretion when determining who will be granted access to these resources. Physician gatekeepers collaborate with patients to identify their healthcare needs and choose services that effectively meet those needs. Public acceptance of gatekeeping is strengthened when there are too few resources to satisfy everyone's demands. In the United Kingdom, where long queues to see specialists are common because specialists are in short supply, the general practitioner gatekeeper has enjoyed widespread support. In the United States, the public perceives …