Study Examines Managed Care ‘Gatekeeping’

A new study published in today's New England Journal of Medicine found "no overall increase" in visits to specialists when the Massachusetts HMO Harvard Vanguard Medical Associates began to allow members to make such visits without a referral from a primary care physician, the New York Times reports (Brody, New York Times, 11/1). Harvard Medical School researchers who conducted the study analyzed 60,000 doctor visits that Harvard Vanguard members made during the three years before the HMO dropped the referral requirement in 1998 and 30,000 doctor visits that members made after the policy shift. According to the study, members visited their primary care physician 1.21 times per six months before the policy shift and 1.19 times after the shift, while the number of visits to specialists before and after the policy shift -- 0.78 times per six months -- did not change. Researchers found a "small increase" in first-time visits to specialists, with the "most significant rise" among members who sought treatment for back pain (Washington Post, 11/1). Dr. Stephen Pearson, a co-author of the study, said, "The bottom line is that in this kind of system, you can offer open access to specialists without breaking the bank and without creating havoc. And that's an important lesson for the health care system." However, researchers cautioned that the results of the Harvard Vanguard study may not apply to other managed care plans (Nano, AP/Newsday, 10/31). Many HMOs began to require patients to receive a referral to visit a specialist in the 1980s and early 1990s to control costs and overuse of specialists. However, the practice, known as "gatekeeping," has "never been popular" among patients and doctors, and many health plans have "relaxed or eliminated" it in the past few years (New York Times, 11/1).

Despite the results of the Harvard Vanguard study, Dr. David Lawrence, chair and CEO of Kaiser Foundation Health Plan and Hospitals, said that Kaiser "strongly encourages" patients to receive a referral from a primary care physician before they visit a specialist. In an editorial accompanying the study, he wrote, "If the patient is left to try and find his or her way through what is a maze of choices and a maze of different opinions and ideas about what should happen, the patient is really at rather substantial risk" (AP/Newsday, 11/1). Dr. William Roper, dean of the University of Carolina School of Public Health, said, "I have no nostalgia for the gatekeeping method. No one is comfortable with a 'Mother may I" approach to health care." He added, however, "We can't go back to the Yellow Pages method of going to whomever you want to and getting whatever you want. That's crazy" (New York Times, 11/1). To view an abstract of the study, go to http://content.nejm.org/cgi/content/abstract/345/18/1312. To listen to an NPR "All Things Considered" report on the study, go to http://www.npr.org/ramfiles/atc/20011031.atc.13.ram. Note: You must have RealPlayer to listen to the report.