Gatekeeper

A gatekeeper refers to requirements that must be met before an individual can qualify for a long-term care plan or to an individual who oversees a patient treatment through a health maintenance organization, or HMO.

Because there are two different definitions for what a gatekeeper is, they can be analyzed separately.

For the first definition, a gatekeeper refers to not to an individual person, but instead, to the requirements that must be met before an individual can receive any payouts from their long-term care insurance plan. The standards are referred to as gatekeepers because they are the gate between the individual and the policy payouts. In order to receive the plan’s benefits, an individual must first qualify based on the policy’s requirements.

For the second definition as used when in the field of health insurance, a gatekeeper describes the person in charge of a patient's treatment. Anyone who receives health insurance coverage through managed care plan, specifically a health maintenance organization or HMO plan, has a gatekeeper assigned to them or allowed to choose one. In some cases, the insured party is instructed to choose a primary care physician from a list, and that doctor becomes the gatekeeper for the patient. In traditional HMO situations, the primary care physician is automatically the gatekeeper for a patient’s entire medical care, from approving tests and treatments to issuing referrals for specialty care within the plan’s network. Gatekeepers are also a common characteristic in managed public healthcare systems, such as in the UK and in Scandinavian countries.

The gatekeeper’s job, theoretically, might be thought of as a way to help the patient manage their care within the system, since a patient may not be aware of all the intricacies, rules and regulations in place, so using a gatekeeper can help streamline the process. Gatekeeping, however, does have its criticisms as well.  

Some of the purported pros of using a medical gatekeeper include keeping healthcare costs down by avoiding unnecessary tests and interventions by having one medical professional be the go-to for care and any secondary care.

Some of the cons of utilizing a medical gatekeeper, on the other hand, have been reported as doctors feeling like they are acting more as administrators than providers giving treatment, concern over primary care providers denying or limiting referrals in order to keep their patient load and thus, payments and patients feeling like they are limited in their healthcare choices.