Are gatekeeper requirements associated with cancer screening utilization?

Health Serv Res. 2004 Feb;39(1):153-78. doi: 10.1111/j.1475-6773.2004.00220.x.


Objective: There is widespread debate over whether health plans should require enrollees to use "gatekeepers," which are primary care providers that coordinate care and control access to specialists. However, little is known about whether health plan gatekeeper requirements improve or reduce quality-of-care. Our objective was to examine whether gatekeeper requirements are associated with the utilization of cancer screening for breast, cervical, and prostate cancer.

Data sources: Three linked sources (N = 13,534): (1) 1996 Medical Expenditure Panel Survey (MEPS) Household Survey, a nationally representative, ongoing survey sponsored by the Agency for Healthcare Research and Quality; (2) 1996 MEPS Health Insurance Plan Abstraction, which codes data from health plan booklets obtained from privately insured respondents, and (3) 1995 National Health Interview Survey.

Study design/data collection: Cross-sectional, multivariate logistic regression analysis using secondary data.

Principal findings: We found in multivariate analyses that women in gatekeeper plans were significantly more likely to obtain mammography screening (Odds Ratio [OR] = 1.22, 95 percent Confidence Interval [CI] 1.07-1.40), clinical breast examinations (OR = 1.39, 95 percent CI 1.23-1.57), and Pap smears (OR = 1.33, 95 percent CI 1.16-1.52) than women not in gatekeeper plans. In contrast, gatekeeper requirements were not associated with prostate cancer screening (OR = 1.11, 95 percent CI 0.93-1.33). We found no association between screening utilization and aggregate plan types (HMO, POS, PPO, FFS).

Conclusions: Gatekeeper requirements are associated with higher utilization of widely recommended cancer screening procedures, but not with utilization of a less uniformly recommended cancer screening procedure. Researchers should consider the analysis of specific plan characteristics rather than aggregate plan types in conducting future research, and insurers and policymakers should consider the potential benefits of gatekeepers with respect to preventive care when designing health plans and legislation.

Publication types

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

MeSH terms

  • Breast Neoplasms / diagnosis*
  • Breast Neoplasms / prevention & control
  • Cross-Sectional Studies
  • Diagnostic Services / statistics & numerical data*
  • Family Practice / standards*
  • Female
  • Gatekeeping*
  • Humans
  • Logistic Models
  • Male
  • Managed Care Programs / statistics & numerical data*
  • Mass Screening / methods
  • Mass Screening / statistics & numerical data*
  • Multivariate Analysis
  • Odds Ratio
  • Ovarian Neoplasms / diagnosis*
  • Ovarian Neoplasms / prevention & control
  • Physician-Patient Relations
  • Primary Health Care / standards*
  • Prostatic Neoplasms / diagnosis*
  • Prostatic Neoplasms / prevention & control
  • Quality Assurance, Health Care
  • Selection Bias
  • United States