Leaving gatekeeping behind--effects of opening access to specialists for adults in a health maintenance organization

N Engl J Med. 2001 Nov 1;345(18):1312-7. doi: 10.1056/NEJMsa010097.


Background: Gatekeeping refers to the prior approval of referrals to specialists by a primary care physician. Although many health plans view gatekeeping as an essential tool for controlling costs and coordinating care, many patients and physicians object to it.

Methods: On April 1, 1998, Harvard Vanguard Medical Associates, a large, multispecialty, capitated group practice previously known as Harvard Community Health Plan, eliminated a gatekeeping system that had been in place for over 25 years. We determined the effects of opening access to specialists on visits to primary care physicians and specialists by adults. In randomly selected cohorts of 10,000 members each, we analyzed visits during 6-month periods for the 3 years before and 18 months after gatekeeping was eliminated.

Results: Adults visited a primary care physician an average of 1.21 times and 1.19 times per six-month period before and after the elimination of gatekeeping, respectively (P=0.05); the average number of visits to a specialist was 0.78 per six-month period both before and after its elimination (P=0.35). There was little change in the percentage of visits to specialists included in the analysis as a proportion of all visits (39.1 percent before the elimination of gatekeeping and 39.5 percent afterward). The percentage of first visits to specialists as a proportion of all visits to specialists included in the analysis increased from 24.7 to 28.2 percent (P<0.001). There were small increases in the numbers of visits to orthopedists and physical or occupational therapists. The proportion of visits to specialists for low back pain that were new consultations increased from 26.6 to 32.9 percent (P=0.01).

Conclusions: In a capitated, multispecialty group practice, we found little evidence of substantial changes in the use of specialty services by adults in the first 18 months after the elimination of gatekeeping.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Cohort Studies
  • Family Practice / statistics & numerical data
  • Gatekeeping / statistics & numerical data*
  • Group Practice, Prepaid / economics
  • Group Practice, Prepaid / organization & administration
  • Health Maintenance Organizations / economics
  • Health Maintenance Organizations / organization & administration*
  • Humans
  • Low Back Pain / therapy
  • Massachusetts
  • Medicine / statistics & numerical data*
  • Occupational Therapy / statistics & numerical data
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Physical Therapy Modalities / statistics & numerical data
  • Primary Health Care / statistics & numerical data*
  • Random Allocation
  • Regression Analysis
  • Specialization*