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Effects of Removing Gatekeeping on Specialist Utilization by Children in a Health Maintenance Organization
Timothy G. Ferris, MD, MPH;
Yuchiao Chang, PhD;
James M. Perrin, MD;
David Blumenthal, MD, MPP;
Steven D. Pearson, MD, MSc
Arch Pediatr Adolesc Med. 2002;156:574-579.
ABSTRACT
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Background The "gatekeeping" model of access to specialty care has been an essential
managed care tool, intended to control costs of care and promote coordination
between generalists and specialists.
Objective To investigate the impact of removing gatekeeping on specialist utilization.
Methods A capitated multispecialty group discontinued a gatekeeping system on
April 1, 1998. We assessed the overall number and distribution of patient
visits to primary care physicians and specialists and initial patient visits
to specialists before and after the removal of gatekeeping. We performed focused
analyses for specific specialties, children with chronic conditions, and children
with specific diagnoses.
Results Elimination of gatekeeping was not associated with changes in the mean
number of visits to specialists (0.28 visits per 6 months before and after
gatekeeping was removed) or the percentage of all child visits to specialists
(11.6% vs 12.1%; 95% confidence interval, 11.3%-11.9% vs 11.8%-12.4%). The
proportion of all specialist visits that were initial consultations increased
after gatekeeping was removed, from 30.6% (95% CI, 29.4%-31.8%) to 34.8% (95%
CI, 33.6%-36.1%). Visits to any specialist by children with chronic conditions
increased from 18.6% (95% CI, 17.7%-19.1%) to 19.8% (95% CI, 19.0%-20.7%).
New patient visits to specialists by children with chronic conditions as a
proportion of all specialist visits increased from 28.1% (95% CI, 25.9%-30.2%)
to 32.3% (95% CI, 30.1%-34.5%).
Conclusions Replacing a gatekeeping system with open access to all specialty physicians
in a managed care organization resulted in minimal changes on the utilization
of specialists. Visits to specialists by children with chronic conditions
increased after the removal of gatekeeping.
INTRODUCTION
PRIOR APPROVAL of specialty utilization by a designated primary care
physician, commonly referred to as "gatekeeping," has been one of the essential
tools of managed care. Gatekeeping was considered a cornerstone of cost containment
in part because of evidence that specialists induced demand for costly and
sometimes unnecessary procedures.1-2
In addition, gatekeeping was intended to enhance patients' contact with generalists,
who provide more preventive, comprehensive, and coordinated care than specialists.3
Although there is evidence for decreased costs and subspecialty utilization
in gatekeeping plans,4-7
gatekeeping is not always associated with lower subspecialty utilization.8-9 Concern about the effects of gatekeeping
on patient-physician relationships has been growing. Patients do not support
the role of a gatekeeper physician.10-11
Physicians report resenting patient suspicions that resource allocation pressures
influence their clinical decisions.10, 12-13
In addition, gatekeeping may result in lower subspecialty utilization for
vulnerable populations, including children with chronic conditions.7 Overall, the effects of gatekeeping on child health
services has received considerably less attention than the effects on adult
populations. The low rates of specialist use among children, particularly
for those with chronic conditions,14 suggests
that underuse of specialists may be a greater problem in the delivery of health
care to children than overuse.
Influenced by these negative perceptions and seeking to gain market
share, some managed care organizations have recently dropped their gatekeeping
requirement.15 What happens when gatekeeping
is eliminated? Only a few articles15 describe
the aftermath of eliminating gatekeeping. We16
previously reported evidence that removing gatekeeping from a capitated multispeciality
group resulted in only small changes in the utilization of specialists by
adults. As a result, specialty care health plans and physician groups contemplating
the elimination of gatekeeping have little information with which to judge
the possible effects on patient behavior and subsequent utilization.
On April 1, 1998, Harvard Vanguard Medical Associates, Boston, Mass,
a capitated multispecialty practice previously known as Harvard Community
Health Plan, eliminated a gatekeeping system that had been in place for more
than 25 years. The goal of this study is to determine the effect of this change
in specialty access on the number and pattern of visits to primary care physicians
and specialists by children.
PATIENTS AND METHODS
SETTING
Previously a staff-model component of Harvard Pilgrim Health Care, Harvard
Vanguard Medical Associates is a multispecialty provider group. During the
time of this study, Harvard Vanguard cared for approximately 140 000
adults and 50 000 children. Harvard Pilgrim insured more than 90% of
all patients. Harvard Vanguard directly employed approximately 50 pediatricians
who served as the primary care physicians for the child population. All physicians
during the time of this study were paid solely by salary, with a 10% withholding
contingent on the budgetary performance of the entire medical group for the
year.
Since the medical group's inception in 1969, patients had been required
to have a referral from a primary care physician to make an appointment with
nearly all specialist physicians. Direct access was already allowed to mental
health, dermatology, and, beginning in 1995, obstetrics and gynecology. Harvard
Pilgrim and Harvard Vanguard decided to end all gatekeeping requirements on
April 1, 1998. Under the new system, patients or their parents were able to
call independently and book any specialty appointment with any of the specialists
available to the primary care physicians. This decision to provide direct
access to specialty providers was communicated to Harvard Vanguard members
through personal letters and posters in the clinics, and it was also advertised
widely throughout the community.
STUDY DESIGN
We compared absolute and relative utilization of specialist services
before and after the removal of gatekeeping at Harvard Vanguard. To appreciate
secular trends, we constructed a 3-year baseline period by analyzing patient
cohorts in 6 time intervals of 6 months' duration before the end of gatekeeping
on April 1, 1998. We compared the use of specialists in these cohorts with
that of 3 subsequent cohorts selected from the period after gatekeeping had
been eliminated. We hypothesized that the removal of gatekeeping might affect
visits in either of 2 ways: (1) there might be an increase in visits to specialists
(with or without a concomitant decrease in visits to primary care physicians8) or (2) there might be an increase in the proportion
of specialist visits that were generated by new, self-referred patients. To
test these hypotheses, we analyzed the absolute rates of visits to generalists
and specialists, the proportion of visits to primary care physicians vs specialists,
and the proportion of new visits vs return visits to specialists.
Because the removal of gatekeeping may not affect the utilization of
different specialists equally, we conducted subanalyses of specialties and
conditions for which we hypothesized that patients might be more likely to
seek specialist care directly. The institutional review board of Harvard Pilgrim
Health Care approved the study.
PATIENTS
Each patient cohort was created by randomly selecting 10 000 eligible
HMO members who were younger than 18 years and continuously enrolled during
each 6-month interval. For individuals selected, all medical claims that occurred
within the 6-month period were copied to a database for analysis. Of 90 000
children identified from eligibility files, 60 had been incorrectly matched
to encounter claims and were subsequently excluded. Each encounter claim contained
the date of visit, place of service, provider specialty, and associated International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM)17 diagnosis
and Physicians' Current Procedural Terminology18 procedure codes. We excluded all encounters not associated
with a face-to-face visit (including radiology and pathology) and encounters
for emergency department visits.
VARIABLES
The principal outcome variable was a face-to-face visit with a physician.
Nurse practitioner and physician assistant visits were not coded in the database
and therefore were excluded. Provider specialty was already assigned to each
claim in the Harvard Vanguard database. Because only internists and pediatricians
were eligible to serve as primary care physicians, these specialties were
grouped as primary care. Specialties included orthopedics, surgery, neurology,
otolaryngology, cardiology, pulmonology, allergy, rheumatology, audiology,
physical therapy, urology, gastroenterology, endocrinology, ophthalmology,
nephrology, podiatry, oncology, speech pathology, and infectious disease.
All references to specialties refer only to the included specialties listed,
unless otherwise indicated. Visits to dermatologists, obstetrician/gynecologists,
and mental health workers were analyzed separately because these visits had
not required a referral under the gatekeeping system.
A first-time patient visit to a specialty department was defined using Physicians' Current Procedural Terminology codes for a
new patient (available from the authors). Physician offices used these codes
to indicate that the identified patient had not been under the care of the
specific specialist physician during the preceding 3 years. Children with
chronic conditions were identified using a previously developed list for identifying
chronic conditions using ICD-9-CM codes.14, 19-20 Any single claim
for a face-to-face visit using an included ICD-9-CM
code (excluding mental health and asthma) was used to define a child with
a chronic condition. The common childhood complaints of asthma (493.XX), headache
(784.0, 307.81, and 350.2), middle ear disease (380-385.9 and 388.6-388.8),
and muscle or joint pain (840-848, 719.4, 719.7, 729.1, 845.0, 726.9, 848.9,
724.2, and V71.9) were identified using ICD-9-CM
codes.
ANALYSIS
We used 3 measures to determine the effects of ending gatekeeping. First,
we calculated the mean visit rate per member by first counting the number
of visits to generalists and specialists for each member, then averaging for
all eligible members during each period. Second, we calculated the percentage
of all visits that were made to primary care physicians and specialists for
each period. Third, we calculated the percentage of visits to specialists
that were new patient visits for each period. To do this, we counted new visits
for specialists and divided by the number of total specialist visits for each
period. We then compared these rates and proportions from before and after
the discontinuation of gatekeeping.
We repeated these same analyses for specific subgroups of patients selected
by age, sex, diagnosis, and specialty. For diagnosis-specific analyses, we
considered only visits to specialists that were relevant to the diagnosis
(allergy and pulmonology for asthma, orthopedics for muscle and joint pain,
etc). For these analyses, we changed the units from visits per child per 6
months to visits per 1000 children per 6 months to increase the relevance
of the data.
Our analysis strategy started with examining the time trend from the
9 periods. In this part of the analysis, multiple (linear or logistic) regression
models were used to adjust for age, sex, or seasonal effects. If the outcome
variables seemed to be stable over time in the baseline period, we simplified
the analysis to focus on the comparisons between data from 1 year before and
1 year after the removal of gatekeeping. t Tests
(2 sample, 2-tailed) or  2 tests, whichever were appropriate,
were used to test the mean differences. Any change in age or sex between the
2 periods was also adjusted using multiple (linear or logistic) regression
models.
RESULTS
STUDY POPULATION
After exclusions, the total number of patients distributed throughout
all 6 cohorts of the baseline period was 59 952 (a total of 167 255
visits). The 3 cohorts after the end of gatekeeping consisted of 29 988
patients (73 754 visits). For all patients, the mean ± SD age
was 7.9 ± 5.3 years, and 49.4% were girls. Although the sex composition
did not change significantly during the study, the mean age of the sample
increased from 7.7 years to 8.3 years during the 4.5-year study (P<.001).
VISITS TO GENERALISTS AND SPECIALISTS
There were only small changes after the lifting of gatekeeping in the
mean number of patient visits to generalists and specialists (Table 1). Children visited a primary care physician an average of
2.16 times (95% confidence interval, 2.12-2.19) per 6-month period before
the removal of gatekeeping and 2.05 times (95% CI, 2.01-2.08) per 6-month
period after the removal of gatekeeping. Rates of visits to eligible specialists
were stable over the baseline period and did not change with the removal of
gatekeeping. First consultation visits to specialists increased from 0.09
visits (95% CI, 0.08-0.09) to 0.10 visits (95% CI, 0.09-0.10) per member per
6 months. There was no significant sex- or age-related differences in the
effects of removing gatekeeping on visit rates to specialists (data not shown).
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Visits to Generalists and Specialists for the Year Before and the Year
After the Removal of Gatekeeping*
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Because care patterns can shift from generalists to specialists without
any change in overall visit rates, we focused on changes in the percentage
of visits to generalists and specialists. As shown in Figure 1, the percentage of visits to primary care physicians and
specialists changed little after gatekeeping was removed. After a stable baseline
period, the percentage of all visits to eligible specialists averaged 10.8%
during the year before removal of gatekeeping and 11.0% during the year after
removal of gatekeeping (P = .29).
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Figure 1. Distribution of child visits to
generalists and specialists in the year before and the year after the removal
of gatekeeping.
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Figure 2 displays the percentage
of visits to specialists as a proportion of all visits included in the analysis
for each of the 6-month periods of the study. There was no significant change
in the percentage of visits to specialists associated with the removal of
gatekeeping (P = .65). Specialist visits averaged
11.6% (95% CI, 11.3%-11.9%) during the year before the end of gatekeeping
and was essentially unchanged at 12.1% (95% CI, 11.8%-12.4%) during the year
after the end of gatekeeping (Table 1).
The only notable change found in association with the lifting of gatekeeping
was an increase in specialist visits by patients for a first-time consultation
from 30.6% (95% CI, 29.4%-31.8%) before the removal of gatekeeping to 34.8%
(95% CI, 33.6%-36.1%) after the removal of gatekeeping (Table 1 and Figure 2).
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Figure 2. Specialist visits as a percentage
of all child visits for each period and first patient visits to specialists
as a percentage of all specialist visits. P= .65 for change in
temporal trend for percentage of visits to specialists. P<.001
for change in temporal trend for first patient visits to specialists. Both
tests were performed using multiple regression models adjusting for age and
season.
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VISITS TO SPECIFIC SPECIALISTS
None of the specialties included in our study had a statistically significant
increase in visits after the removal of gatekeeping. The only suggestion of
an effect was found in visits to allergists, for whom visits increased from
46.5 visits per 1000 children per year before the removal of gatekeeping to
54.5 visits per 1000 children per year after the removal of gatekeeping (P = .06).
SPECIALIST VISITS FOR SPECIFIC CONDITIONS
There were no significant increases over time in the rate of child visits
to specialists among children with the 4 specific conditions we studied (Figure 3). A small increase in the rate of
visits to specialists by children with chronic conditions was not significant.
Nonetheless, the percentage of visits to specialists as a proportion of all
visits to generalists and specialists increased from 18.6% (95% CI, 17.7%-19.1%)
to 19.8% (95% CI, 19.0%-20.7%). For children with chronic conditions, initial
consultations to specialists as a percentage of specialist visits increased
from 28.1% (95% CI, 25.9%-30.2%) to 32.3% (95% CI, 30.1%-34.5%). The increase
in specialist visits for children with chronic conditions occurred primarily
in orthopedics.
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Figure 3. Specialist visits as a proportion
of all primary care physician and eligible specialist visits by diagnosis
before and after the removal of gatekeeping. Chronic conditions refers to
all children who had any visit-based billing diagnosis of a chronic condition
(see the "Patients and Methods" section).
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COMMENT
This study of the effect of removing the gatekeeping requirement in
a capitated multispecialty group found little evidence for substantial changes
in specialist utilization by children in the first 18 months after the end
of gatekeeping. The percentage of visits to specialists by first-time patients
increased somewhat, but overall we found a negligible change in the mean rate
of visits to both generalists and specialists, and we found no increase in
the percentage of all visits to specialists.
Our only suggestion of a possible overall effect was the increase in
the proportion of visits to specialists by first-time patients. This increase
amounted to 22 additional first-time consultations per 1000 child members
in a 6-month period. Although this increase in first-time consultations to
specialists did not result in an overall increase in specialist visits at
Harvard Vanguard, a different practice setting with different availability
of specialists may demonstrate an increase in overall visits to specialists.
If patients do not like gatekeeping, why did we not find larger increases
in specialty use associated with the removal of gatekeeping? First, even the
studies demonstrating changes in utilization with the initiation of gatekeeping
found only relatively small decreases in specialty utilization.5
Eisenberg21 pointed out in 1986 that gatekeeping
was a relatively weak intervention for controlling the costs of care associated
with physician decisions. Forrest and colleagues22
found that self-referral was relatively uncommon even when patients had the
option. In addition, stopping gatekeeping is not the same as starting it.
One anecdotal study15 found minimal effect
associated with the removal of gatekeeping. Another study8
compared expenditures in a gatekeeping plan with those in a more open-access
arrangement and found small differences between them. Parents already enrolled
in a managed care plan may have a lower propensity to use specialty services
or a lower propensity to seek specialty care directly, thus minimizing the
effect of an administrative mechanism such as gatekeeping. Also, habits are
slow to change. It may take longer than 1.5 years for a change in established
care-seeking patterns to occur. In addition, the threshold for referral to
specialists before the discontinuation of gatekeeping may have been low, thus
minimizing the effect of stopping gatekeeping. Finally, patients may have
preferred to see their primary care physician first if they found the wait
to see a specialist to be excessive.
There were 3 findings in our study that may merit further investigation.
First, we found an increase in new patient visit rates to specialists associated
with the removal of gatekeeping. The ability of specialists to accommodate
more first-time patients without increasing overall visit rates (presumably
by scheduling fewer follow-up visits) is rarely considered when assessing
the effect of administrative and financial changes on specialty visit rates.
It may be worth investigating whether this substitution affects the costs
and quality of specialty care for children.
Second, our results suggest that the removal of gatekeeping may have
resulted in a relative increase in visits to allergists. Our results are consistent
with those of Forrest et al,22 who found a
greater likelihood of self-referred visits for allergic conditions. Allergic
phenomena are increasingly common in child populations, and there may be some
pent-up demand among parents of children with allergies or suspected allergies
to consult a specialist. The effect of gatekeeping on costs and quality of
care (including patient and physician satisfaction) for this set of conditions
deserves further investigation.
Third, new patient visits to specialists (mostly orthopedics) for children
with chronic conditions increased after gatekeeping was removed. If this increase
reflected real changes in specialty care–seeking behavior by parents
of children with chronic conditions, then the requirement for previous approval
for specialist visits in this population may be a significant barrier to access
to care.
This study has several limitations. We studied a single, well-established,
capitated multispecialty group in a particular health care market, and our
results may not be generalizable to other organizations (such as an independent
practice association) or markets. Specifically, the patients were a stable
population, most of whom had parents who had made a choice to be a member
of a health maintenance organization with gatekeeping. Therefore, this population
may have a lower propensity to seek specialty care outside of their primary
care relationship. We did not study referrals made by physicians, and it is
possible that these changed in ways that were not detected by the measure
(visits) used in this study. We did not assess costs associated with utilization.
It was possible that use of high-cost procedures increased with the increase
in new patient visits to specialists, although in the context of the overall
findings of this study, any increase in costs was likely to be small. Finally,
we are not able to comment on the effects of the removal of gatekeeping beyond
18 months.
Gatekeeping has been one of the principal means that health care managers
have used to reduce inappropriate utilization. Despite some limited evidence
that gatekeeping has been modestly effective on cost reduction, the effect
of gatekeeping on quality of care and outcomes for children has not been thoroughly
evaluated. Recent work has been critical of gatekeeping for the pressures
it places on physicians and patients, but health care managers have had little
empirical data on which to base decisions regarding the usefulness of gatekeeping
and the possible fiscal consequences of removing this barrier to specialty
care. This study of health services utilization before and after the discontinuation
of gatekeeping suggests that stopping a gatekeeping requirement for commercially
insured patients in a multispecialty group practice does not necessarily result
in increased specialist visits.
| What This Study Adds
Gatekeeping, the requirement for preauthorization of specialist visits,
is common in managed care, yet the effect of this administrative requirement
on rates of visits to specialists by children is unknown. In this study, the
removal of gatekeeping had minimal effects on the utilization of specialists
by children. Children with chronic illness were more likely to visit a specialist
after the removal of gatekeeping.
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AUTHOR INFORMATION
Accepted for publication February 7, 2002.
This study was funded by a grant from the Harvard Pilgrim Health Care
Foundation and by Pediatric Scientist Development Award AAP/NICHD K12-HD00850
(Dr Ferris).
We thank Irina Miroshnik, MS, for data management and Ellie MacDonald,
BS, for assistance with manuscript preparation.
Corresponding author and reprints: Timothy G. Ferris, MD, MPH, Massachusetts
General Hospital/Partners Institute for Health Policy, 50 Staniford St, 9th
Floor, Boston, MA 02114 (e-mail: tferris{at}partners.org).
From the Institute for Health Policy, Division of General Internal
Medicine, Massachusetts General Hospital/Partners Healthcare System and Harvard
Medical School (Drs Ferris and Blumenthal), the Medical Practices Evaluation
Center, Massachusetts General Hospital and Harvard Medical School (Dr Chang),
the Center for Child and Adolescent Health Policy, Division of General Pediatrics,
MassGeneral Hospital for Children and Harvard Medical School (Drs Ferris and
Perrin), and the Department of Ambulatory Care and Prevention, Harvard Pilgrim
Health Care and Harvard Medical School (Dr Pearson), Boston.
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