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Thomas Bodenheimer, MD; Bernard Lo, MD; Lawrence Casalino, MD, PhD

JAMA. 1999;281:2045-2049.

Primary care gatekeeping, in which the goal of the primary care physician (PCP) is to reduce patient referrals to specialists and thereby reduce costs, is not an adequate system in which to practice medicine. However, returning to the pre–managed care model of uncoordinated open access to specialists is a poor solution. The primary care model should be retained, but PCPs should be transformed from gatekeepers into coordinators of care, in which the goal of the PCP is to integrate both primary and specialty care to improve quality. Changes in the PCP's daily work process, as well as the referral and payment processes, need to be implemented to reach this goal. This model would eliminate the requirement that referrals to specialists be authorized by the primary care physician or managed care organization. Financial incentives would be needed, eg, to encourage PCPs to provide management of complex cases and discourage both overreferral and underreferral to specialists. Budgeting specialists should control excess costs that might be created by the elimination of the primary care gatekeeper. Pilot projects are needed to test and refine this model of PCP as coordinator of care.

Author Affiliations: Department of Family and Community Medicine (Dr Bodenheimer) and Program in Medical Ethics and Division of General Internal Medicine (Dr Lo), University of California at San Francisco School of Medicine; and Stanford Coastside Medical Clinic, Stanford, Calif (Dr Casalino).

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