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Chiropractic Research Review

Are Referrals Really Necessary?

Requiring the referral of a primary care physician to visit a specialist, known as "gatekeeping," is a traditional procedure in managed care, designed to control costs, provide comprehensive care, and eliminate unnecessary use of services.

Many physicians and their patients object to the restrictive nature of gatekeeping, and it has been eliminated in some managed-care organizations. Information on the effects of eliminating gatekeeping is limited.

To determine the effects of eliminating mandatory gatekeeping on the number of visits and treatment patterns related to primary care physicians and specialists, the authors followed the elimination of a gatekeeping system through the Harvard Vanguard Medical Associates, a capitated, multispecialty group practice. Visits for three years before and 18 months after the 25-year-old gatekeeping system was removed were analyzed in nine 10,000-member cohorts of adults (six at baseline; three after elimination).

Results: There was no significant change in number of visits to either primary care physicians or specialists after eliminating gatekeeping. There was also no significant change in the percentage of visits to specialists (as a proportion of total visits) when referrals were unnecessary. First visits to specialists increased slightly, from 24.7% to 28.2%. Visits to back-pain specialists, orthopedists, and physical/occupational therapists showed slight increases, from 26.6% to 32.9%.

The overall results showed little evidence of substantial changes. However, the authors conclude, "Our results suggest that the elimination of gatekeeping may have resulted in a relative increase in visits to specialists for low back pain." They suggest that the increase may be due to the prevalence and difficulty in treating LBP.

Ferris TG, Chang Y, Blumenthal D, et al. Leaving gatekeeping behind - effects of opening access to specialists for adults in a health maintenance organization. The New England Journal of Medicine 2001:345(18), pp. 1312-1317.

Chiropractic Research Review

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