PRIMARY CARE: From ‘Gatekeeper’ to ‘Coordinator’ Model?
A "Policy Perspectives" piece in this week's Journal of the American Medical Association by Drs. Thomas Bodenheimer, Bernard Lo and Lawrence Casalino argues that with primary care physicians (PCPs), specialists and patients all unhappy with PCPs' role under managed care, the "gatekeeper" concept needs to be reevaluated. The authors write, "We do not support a return to the pre-managed care structure, in which many patients accessed specialists without coordination from a PCP; primary care must be enhanced, not marginalized. Nor do we favor gatekeeping -- patients deserve access to the expertise of specialists." Instead, they propose a middle road that enables "PCPs to facilitate, rather than impede appropriate access. ... Primary care physicians must cease acting as gatekeepers and instead serve as coordinators of care." Bodenheimer et al. suggest forming primary care teams made of up a combination of PCPs, nurse practitioners, physician assistants and RNs; making "team members available to call patients for follow-up"; utilizing computerized data systems and using specialists as PCPs for patients with chronic diseases such as asthma.
Noting that such reforms will need the cooperation of managed care organizations, the authors write that PCPs "should no longer need to give or obtain authorization for patients to see specialists," and should receive positive financial incentives such as "additional payment for taking care of complex patients." They also call for an end to "bonus payments tied to the restriction of specialty referrals," and recommend that specialists receive capitated or salary-based compensation (6/2 issue).