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HLT 205 Week 4 Discussion Question One

HLT 205 Week 4 Discussion Question One


Explain how gatekeeping reduces health care costs in the U.S. Is gatekeeping the most effective strategy for reducing health care costs, or are there more effective strategies that are currently being used?  Explain your reasoning with the support of references.

Gatekeeping in health care is a response to a shortage of specialists and a need to control healthcare expenditure.1 In gatekeeping systems, patients are required to visit a GP or primary care physician to authorise access to specialty care. However, the effectiveness of gatekeeping in controlling expenditure remains unclear. On an individual patient level, one study of private health insurance found

HLT 205 Week 4 Discussion Question One

HLT 205 Week 4 Discussion Question One

that mean annual total health expenditure was lower for patients with health insurance plans that required primary care gatekeeping to authorise specialist referrals than for those with an indemnity (non-gatekeeping) plan.2 However, the percentage of gross domestic product spent on health does not differ significantly between countries with and without gatekeeping models of health care.3

A previous review, capturing literature up to January 2010, found that gatekeeping was related to lower health service use and lower health expenditure. However, there was great variability in the magnitude and direction of the differences, and the impact on health-related and patient-related outcomes was still inconclusive.4 The question remains whether gatekeeping is linked to any adverse health effects. A few studies have suggested that gatekeeping causes delayed diagnoses of cancer.5,6 In the UK — a healthcare system with strong gatekeeping — poor survival rates for breast, colorectal, and lung cancers compared with other European countries have been partly attributed to delayed diagnoses.6

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Considering the potential impact of gatekeeping policy on patients and healthcare systems,3,5 there is a need for an updated systematic review to support healthcare policy. The aim of this study was to identify the effects of primary care physician gatekeeping on quality of care, health outcomes, use and expenditure, and physician and patient attitudes.

Background GPs often act as gatekeepers, authorising patients’ access to specialty care. Gatekeeping is frequently perceived as lowering health service use and health expenditure. However, there is little evidence suggesting that gatekeeping is more beneficial than direct access in terms of patient- and health-related outcomes.

Aim To establish the impact of GP gatekeeping on quality of care, health use and expenditure, and health outcomes and patient satisfaction.

Design and setting A systematic review.

Method The databases MEDLINE, PreMEDLINE, Embase, and the Cochrane Library were searched for relevant articles using a search strategy. Two authors independently screened search results and assessed the quality of studies.

Results Electronic searches identified 4899 studies (after removing duplicates), of which 25 met the inclusion criteria. Gatekeeping was associated with better quality of care and appropriate referral for further hospital visits and investigation. However, one study reported unfavourable outcomes for patients with cancer under gatekeeping, and some concerns were raised about the accuracy of diagnoses made by gatekeepers. Gatekeeping resulted in fewer hospitalisations and use of specialist care, but inevitably was associated with more primary care visits. Patients were less satisfied with gatekeeping than direct-access systems.

Conclusion Gatekeeping was associated with lower healthcare use and expenditure, and better quality of care, but with lower patient satisfaction. Survival rate of patients with cancer in gatekeeping schemes was significantly lower than those in direct access, although primary care gatekeeping was not otherwise associated with delayed patient referral. The long-term outcomes of gatekeeping arrangements should be carefully studied before devising new gatekeeping policies.

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