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For years, specialists and the organizations that represent them have been lobbying hard against the mainstay of most managed care organizations (MCOs): the primary care physician as gatekeeper. The gatekeeper model, they claim, reduces patient access to specialists and specialty teams who can better care for chronic illness and places too much responsibility in the hands of primary care physicians.
Now, as efficient management of chronically ill populations becomes imperative to the survival of MCOs, specialists may finally be getting their wish.
Consider this: According to the Washington, DC-based American Association of Health Plans (AAHP), 92% of American workers with employer-sponsored coverage already have the option of choosing doctors and hospitals outside of a selected network. In addition, open-panel health plans, such as point of service (POS) plans, which offer patients access to a broader range of providers than traditional, closed-panel health maintenance organizations (HMOs), account for much of the recent growth in managed care penetration. And a full 20% of POS claims dollars last year went out of network.
The public demand for greater patient access to specialty services in particular has caused leading MCOs like Blue Shield of California and Oxford Health Plans of Norwalk, CT, to respond by introducing "gatekeeperless" products and improving patient access to disease management services, says Don White, spokesman for AAHP.
Francine Gaillour, MD, an internist with Seattle-based Group Health and medical director of PHAMIS Inc., an information systems firm also in Seattle, believes the trend away from the primary care physician as gatekeeper was inevitable. "I am a gatekeeper," she says. "And one of the things that I’ve known for a real long time is that this idea of family practice or internal medicine physicians being the primary care physician for any group of people is totally false."
Gaillour says that when it comes to chronically ill patients, primary care gatekeepers serve mainly to delay access to proper care. "A primary care physician sees that a patient’s illness is too complex and refers the patient to a specialist," she says. "What I’m saying is that we need to be more proactive. When a patient is first enrolled in a plan or first comes into the clinic and they’ve got seven out of 10 criteria, when you need only six to put them in a high-risk category, the decision needs to be made earlier to refer them for long-term chronic care. Don’t piecemeal referrals."
Rather than the primary care physician monitoring the care and treatment progress of a severely asthmatic patient, Gaillour advocates a system that sends the acute asthma patient directly to a pulmonologist a suggestion echoed in the Bethesda, MD-based National Heart, Lung and Blood Institute’s recent asthma guidelines.
Because most of the patient’s care will revolve around his or her chronic illness, Gaillour says, a specialist should become gatekeeper for that patient and refer the patient to a family practice physician or internist for the few general ailments or treatments the patient may require. To determine whether the patient fits into this category, Gaillour suggests the development of clinical guidelines to determine a patient’s status.
Richard Bringewatt, president and CEO of the National Chronic Care Consortium in Bloomington, MN, says that such an approach has the benefit of providing a focus for managing a disease "as the condition evolves over time, rather than getting hung up in the organization of care management around a setting or in reaction to a specific crisis event."
But, he contends, that kind of disease management approach "crosses a line of effectiveness" when it’s uncoupled from everything else that’s going on in a system.
"It isn’t that there should or shouldn’t be chronic disease management," he says. "It’s a matter of how it should be done. And from my standpoint, it’s critical that it be part of an integrated delivery system. That doesn’t mean that there isn’t a special focus, a special track, a special orientation, a special set of protocols. It’s just that the specialness of it needs to be done within the context of a system." He adds that the question of whether a primary care physician or a specialist should coordinate a given patient’s care also needs to be based on context and dependent upon the particular needs of the patient.
Cyril Hetsko, MD, a primary care physi- cian who practices internal medicine at Dean Medical Center in Madison, WI, has worked within a managed care environment for 20 years. The system in which he works has never had a "strict gatekeeper" system, and patients have always been able to self-refer to specialists within the system. "I think there always has to be some type of provision that if they want to see somebody else [other than their primary care physician], they not be locked out of doing that," says Hetsko, who also serves on the board of directors of the Washington, DC-based American Society of Internal Medicine (ASIM). "But they may have more of a personal responsibility for paying a partial cost of that opt-out. Even ASIM has been in favor of point-of-service options and considerations in any plan."
Even so, Hetsko argues that the idea of disease managers assuming the role of gatekeeper for chronically ill patients doesn’t reflect reality. "People are always complex," he says. "And if they have a chronic condition, it’s usually not by itself, especially as they get older. They usually have a number of interrelating and maybe non-interrelating conditions. And as such, I don’t think that you can have a whole bunch of [algorithms] that are going to just simply deal with one illness."
Because of the existence of comorbid conditions in many patients, Hetsko believes it’s key that a primary care physician be involved in pulling disease management teams together in service of a particular patient. "They may make use of specialists in particular areas, but there has to be a coordinator, and I think that primary care physicians, on the basis of training, are the ones who are best able to do that."
Bringewatt is also concerned by possible problems with continuity of care for patients with multiple chronic conditions but insists that effectively managing those patients isn’t necessarily an either/or proposition.
"I think that the issue of whether to go to a specialty physician vs. a primary care physician sometimes gets people fired up around issues of rights," Bringewatt says. "That’s important, of course, but it blurs out other choice considerations that are also important to people with chronic diseases and disabilities."
He adds that patients today often unrealistically expect and demand a choice of provider, low cost, and high quality. "You can get two out of three, but if you try to do all three, it’s an oxymoron. Framing the question with just the right to go to a physician or a specialist directly makes a complex problem simplistic, and you end up making bad decisions as a result."
"[As clinicians], our primary concern is to be an advocate working on behalf of the patient," Hetsko says. "I think that is a key consideration as we approach these types of programs and plans. If one is having a disease management system, we still have to collaborate and should collaborate with the physician who is acting as the patient’s advocate and care coordinator."
"There’s disagreement," White acknowledges. "And the answer is that people need to work together on this, no matter what side you do it from. That’s really the important thing, and that’s what disease state management is all about: coordinating the care that’s delivered."
[For more information about gatekeeping, contact: Francine Gaillour, MD, PHAMIS Inc., 1001 4th Avenue Plaza, Suite 1500, Seattle, WA 98154. Telephone: (206) 622-9558. Richard Bringewatt, president and CEO, National Chronic Care Consortium, 8100 26th Ave. South, Suite 120, Bloomington, MN 55425. Telephone: (612) 858-8999. Cyril Hetsko, MD, Dean Medical Center, 1313 Fish Hatchery Road, Madison, WI 53715. Telephone: (608) 252-8174. Donald White, American Association of Health Plans, 1129 20th St., NW, Suite 600, Washington, DC 20036. Telephone: (202) 778-3200.]