What Is a Gatekeeper?

There are two definitions of the term "gatekeeper," one used in relation to health insurance and one regarding long-term care plans.

When used in relation to health insurance, gatekeeper describes the person in charge of a patient's treatment. Anyone who receives health insurance coverage in the form of a managed care plan, specifically a health maintenance organization (HMO) plan, is assigned a gatekeeper 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.

A gatekeeper's duty primarily is to manage a patient's treatment. This means the gatekeeper is in charge of authorizing the patient's referrals, hospitalizations and lab studies. When a patient falls ill or needs to be referred to a specialist, the patient contacts the gatekeeper who, in turn, refers the patient to doctors and specialists within the plan network. (To learn more about managed care plans, read: How to Choose a Healthcare Plan.)

The concept of a primary care physician as a gatekeeper to specialists and other medical resources—considered to be a managed care innovation in the United States—has become ubiquitous in recent years. Its introduction has been accompanied by government-sponsored research in the UK into primary care referrals. This research may help shape how the UK's National Health Service (NHS) could shape the gatekeeping function of general practitioners.

Many consider gatekeeping to be an effective way to contain costs by reducing unnecessary medical care interventions. Primary level healthcare and affiliated tests and diagnosis are on average less expensive than secondary and specialty care services. Primary care physicians are understood to be better informed than their patients in regards to where and how to seek specialist care. This knowledge benefits the patient care path by making a more efficient search for an adequate and qualitative secondary care provider.

In a 2014 study that compared non-gatekeeping Austria and gatekeeping USA, Austrian patients were shown to seek help from specialists more frequently than in the USA. The study revealed that lack of a system for governing primary to secondary and tertiary care referrals, such as Austria, led to a high over-utilization of secondary and tertiary care facilities. On the other hand, Austrian patients consistently report a high satisfaction rate with their healthcare system, and Austria has increased its hospital capacity to accommodate the high influx of primary care needs.

Another study of the Dutch healthcare system reported that primary care physicians felt like they were relegated to administrators, when placed in the position of gatekeeper.

This presented an issue because the average age of patients seen by primary care physicians was increasing, and elderly aged patients are more likely to present a plurality of medical ailments and require more robust medical care. In a traditional gatekeeping mechanism, this elderly individual would be sent to several specialists, which is tiring, time-consuming and a potentially a fragmented approach to their healthcare. An ideal gatekeeping system would embrace innovative solutions, multiple competence centers, clinics with multiple care options onsite, and ambulatory care improvements.

In the British healthcare system, general practitioners, who are comparable to primary care physicians in the U.S., are compensated for their services via capitation rates and or fee-for-services, which creates competition on the market for patients. It also creates a situation, where if a general practitioner hands over patients to a specialist too quickly, they could lose part of their funding. On the other hand, if a GP is too careful or reserved with forwarding patients to specialists, the patient may feel denied access to secondary healthcare.

In regards to long-term care, gatekeepers are not people, but rather the requirements that must be met before an individual can receive any payouts from their long-term care insurance plan.

Most long-term care insurance policies require long-term care to be medically necessary for sickness or injury. As a result, most companies conduct their own evaluations of whether this standard is met, and they sometimes overrule patients' doctors. Some policies require the patient to be unable to complete a certain number of daily activities on their own, such as bathing, walking, dressing, and eating.

There are both negative and positive aspects to gatekeeping, for both the healthcare system and individual patients. It is clear that improvements must be made to enable flexible and easy communication between the care providers of distinct entry points. A GP should be able to quickly consult a specialist to confirm or eliminate clinical concerns, and a specialist should be able to pass detailed instructions to a GP for potential follow-ups.