Source: Ferris TG, Chang Y, Perrin JM, et al. Effects of removing gatekeeping on specialist utilization by children in a health maintenance organization. Arch Pediatr Adolesc Med. 2002;156:574–579.A large Boston academic-affiliated, capitated multi-specialty group discontinued its gatekeeper system in 1998, in which all specialty referrals needed to go through a primary care provider. Using claims data, the authors from the Harvard Vanguard Medical Associates and Harvard Pilgrim System evaluated the utilization by 29,988 children for 1 year after the end of gatekeeping with a comparable group for the last full year with gatekeeping. The variable measured was patient office visits to primary care physicians (PCP) and subspecialty care physicians (SCP). An additional study of these visit patterns by children with chronic conditions and specific diagnoses was also done.Their results showed a small but statistically significant difference in PCP visits with and without gatekeeping: the mean numbers of PCP visits in 6 months were 2.16 (95% CI, 2.12–2.19) and 2.05 (95% CI, 2.01–2.08) respectively (P<.05). The mean number of SCP visits in 6 months showed no apparent change: .28 visits with and without gatekeeping. When measured as a percent of all visits, SCP visits accounted for 11.6% with gatekeeping (95% CI, 11.3%–11.9%) and 12.1% without it (95% CI, 11.8%–12.4%) (P=.65). However, initial visits to SCPs increased after gatekeeping was removed: from 30.6% (95% CI, 29.4%–31.8%) to 34.8% (95% CI, 33.6%–36.1%) (P<.001). Children with chronic conditions showed higher numbers of visits to all providers, but similar trends. There were no significant increases in rate of SCP visits over 6 months (P=.06).When measured as a percent of all visits, SCP visits for children with chronic conditions accounted for 18.6% (95% CI, 17.7%–19.1%) with gatekeeping and 19.8% (95% CI, 19.0%–20.7%) without it (P-value not stated). New visits varied from 28.1% (95% CI, 25.9%–30.2%) with gatekeeping to 32.3% (95% CI, 30.1%–34.5%) without it (P-value not stated).Gatekeeping has been felt to decrease utilization and cost to the plan while promoting the use of the PCP to provide the patient with coordinated and preventive care. These authors investigated this hypothesis only 1 year after cessation of gatekeeping in a health plan with patients who appeared to be accustomed to using their PCP as a gatekeeper. Their results appear to be similar to those of other types of health plans that removed gatekeepers or never had gatekeepers.1,2 Patient satisfaction is lower in gatekeeper plans2,3 and is one of the reasons why health plans have been easing SCP referrals for patients. Additional reasons include higher plan administrative expenses in gatekeeper models and increased physician paperwork requirements with concomitant physician dissatisfaction.New visits to specialists increased after cessation of gatekeeping for all children, but overall SCP visits remained level during both periods. The overall visit rate remaining constant may indicate that the PCP could have taken care of the patient’s needs without a specialist referral. Interestingly, these authors concluded in another study4 study that parents of children with chronic needs do not readily join health plans with gatekeepers. The need for increased SCP initial visits for the general patient population and SCP visits for children with chronic conditions should be investigated further.Studies such as this one, patient and physician dissatisfaction with limited access to SCPs in the gatekeeper model, and the dropping of gatekeeper requirements in large national health plans are causing HMOs to re-think their utilization methodology. It appears that the gatekeeper may soon be history.