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What is a Gate Keeper?

Gail Carlson, MPH Ph.D, State Health Education Specialist, University of Missouri Extension

Many types of managed care plans use primary care physicians as gate keepers to control costs and coordinate health care services for their members. When individuals join a plan, they are provided a list of physicians who are part of the managed care network. Members are expected to select one of the primary care doctors on the list. Before making a final selection, find out if the doctor is accepting new patients from your managed care plan. Some limit the number of managed care patients they will accept. Besides it is a good idea to interview the doctor in order to find out if this is someone you can work with. A primary care provider is usually a family practitioner or a general internist. For a woman, it might be a gynecologist. For younger patients, a pediatrician or family practitioner usually handles routine care.

Under some managed care plans, the member is expected to contact their primary care provider before receiving any health care. This is where the term gate keeper comes from. Many plans require that the individual's primary care doctor make a formal referral to a specialist. If the individual makes an appointment for a specialist without the referral, he may be responsible for all or most of the specialist's bill.

There are some advantages to having a primary care provider. It is estimated that 90% of an individual's medical needs can be met by a primary care physician in the office. Since primary care doctors typically charge less, the cost of health care is reduced. Under ideal conditions, the primary care provider functions much like the traditional family doctor. He focuses on the health of the whole person rather than on a single organ system in the body. He emphasizes the importance of prevention and establishes a schedule for age-appropriate health screening. When a suspected problem does exist, he can make the initial diagnosis, advise the patient on further treatment and make necessary referrals. The fact that all medical records are kept in one location also contributes to care that is better coordinated.

One concern about this approach is that too few services will be provided. In order to control costs the "gate keeper" may limit access to specialists or more costly tests and procedures. However, most plans (at least HMOs) are required to have a formal grievance procedure. To insure the quality of their care, members should become familiar with their plan's grievance procedure, and be assertive about using such procedures when they believe the quality of their care is inadequate. There is another safeguard. Doctors know that poorer health outcomes and higher costs can result when care is not adequate or delayed. Therefore, whether practicing in managed care networks or under conventional insurance plans, good doctors are likely to continue to provide quality care in a timely manner.



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Last Updated 05/05/2009