Gatekeeping Arrangements in Widespread Use

Forty percent of insured Americans reported being enrolled in gatekeeping arrangements where their primary care physician controlled access to specialist care. Data from two surveys conducted by the Center for Studying Health System Change showed just how deeply embedded this feature had become in the American health insurance system. More than half of insured individuals in Boston (62 percent) and Phoenix (54 percent) were subject to gatekeeping. Even in communities with comparatively low gatekeeping rates -- Greenville, South Carolina (31 percent) and Syracuse (35 percent) -- roughly one in three insured people had a primary care gatekeeper managing their referrals.

Supporters of gatekeeping maintained that having a single physician oversee and coordinate all of a patient's care led to better quality and lower costs by cutting back on unnecessary or inappropriate specialty services. This coordinating function of primary care doctors was seen as especially valuable for patients with chronic conditions, who were more likely to see multiple physicians.

Opponents, however, raised concerns that gatekeeping systems -- particularly when paired with administrative hurdles and financial incentives aimed at reducing costs -- could block patients from seeing specialists even when those services would genuinely benefit them.

Physician Participation Is High

Despite widespread physician reluctance and ongoing unease about gatekeeping, the Center found that 91 percent of primary care physicians in the United States served as gatekeepers for at least some of their patients. The reach of this trend was remarkable: 96 percent of physicians in group practices acted as gatekeepers, and even among those in solo or two-physician practices -- where one might expect less managed care involvement -- 88 percent served in the gatekeeper role.

On average, primary care physicians who functioned as gatekeepers did so for about 4 out of every 10 patients. The proportion of patients subject to gatekeeping varied by specialty: general pediatricians served as gatekeepers for 52 percent of their patients, while general internists (40 percent) and family practitioners (39 percent) had somewhat lower rates.

Physician Participation in Gatekeeping by Practice Type and Specialty

The Community Tracking Study data broke down gatekeeping participation along several dimensions. Overall, 91 percent of all primary care physicians served as gatekeepers, managing an average of 42 percent of their patient panels in this capacity.

By practice type, the differences were clear. Solo or two-physician practices had 88 percent participation, with gatekeeping responsibilities covering 35 percent of their patients. Group practices with three or more physicians showed 96 percent participation (significantly higher), covering 41 percent of patients. Group- or staff-model HMOs had 94 percent participation (also significantly higher), but their physicians served as gatekeepers for 78 percent of their patients -- nearly double the rate of other practice settings.

By specialty, general pediatricians led with 93 percent serving as gatekeepers for 52 percent of their patients. General internists followed at 90 percent participation for 40 percent of patients (significantly different from pediatricians), and family practitioners at 91 percent for 39 percent of patients (also significantly different from pediatricians).

What the Numbers Meant for the Health System

The near-universal adoption of gatekeeping among primary care physicians -- even those in smaller, independent practices -- indicated that this managed care mechanism had become a standard feature of American medical practice by the late 1990s. It was no longer confined to large group practices or staff-model HMOs. The question was no longer whether physicians would participate in gatekeeping, but rather how broadly it would apply to their patient populations.

The relatively high proportion of patients in gatekeeping within HMO settings (78 percent) compared to other practice types reflected the tighter organizational control these plans exerted over referral patterns. For the broader health system, the data raised ongoing questions about whether gatekeeping was genuinely improving care coordination or simply adding bureaucratic layers that frustrated patients and physicians alike.

Sources and Further Reading

This Data Bulletin presents findings from the Community Tracking Study, conducted by the Center for Studying Health System Change. The study included both a Household Survey of the civilian, non-institutionalized population and a Physician Survey covering primary care doctors across 12 randomly selected metropolitan areas and a nationally representative sample.