Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists

JAMA. 1999 Jul 21;282(3):261-6. doi: 10.1001/jama.282.3.261.


Context: Few data are available regarding how patients view the role of primary care physicians as "gatekeepers" in managed care systems.

Objective: To determine the extent to which patients value the role of their primary care physicians as first-contact care providers and coordinators of referrals, whether patients perceive that their primary care physicians impede access to specialists, and whether problems in gaining access to specialists are associated with a reduction in patients' trust and confidence in their primary care physicians.

Design, setting, and patients: Cross-sectional survey mailed in the fall of 1997 to 12707 adult patients who were members of managed care plans and received care from 10 large physician groups in California. The response rate among eligible patients was 71%. A total of 7718 patients (mean age, 66.7 years; 32 % female) were eligible for analysis.

Main outcome measures: Questionnaire items addressed 3 main topics: (1) patient attitudes toward the first-contact and coordinating role of their primary care physicians, (2) patients' ratings of their primary care physicians (trust and confidence in and satisfaction with), and (3) patient perceptions of barriers to specialty referrals. Referral barriers were analyzed as predictors of patients' ratings of their physicians.

Results: Almost all patients valued the role of a primary care physician as a source of first-contact care (94%) and coordinator of referrals (89%). Depending on the specific medical problem, 75% to 91% of patients preferred to seek care initially from their primary care physicians rather than specialists. Twenty-three percent reported that their primary care physicians or medical groups interfered with their ability to see specialists. Patients who had difficulty obtaining referrals were more likely to report low trust (adjusted odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2) with their primary care physicians.

Conclusions: Patients value the first-contact and coordinating role of primary care physicians. However, managed care policies that emphasize primary care physicians as gatekeepers impeding access to specialists undermine patients' trust and confidence in their primary care physicians.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Attitude to Health*
  • California
  • Cross-Sectional Studies
  • Female
  • Health Care Surveys
  • Health Services Accessibility
  • Humans
  • Logistic Models
  • Male
  • Managed Care Programs
  • Middle Aged
  • Patient Satisfaction / statistics & numerical data*
  • Physician-Patient Relations
  • Physicians, Family / statistics & numerical data*
  • Primary Health Care / standards*
  • Referral and Consultation / statistics & numerical data*
  • Trust