This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (41)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA

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).

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

The Medical Home: Locus of Physician Formation
Daaleman
J Am Board Fam Med 2008;21:451-457.
ABSTRACT | FULL TEXT  

Accreditation Council for Graduate Medical Education Competencies: Practice-Based Learning and Systems-Based Practice
Moskowitz and Nash
American Journal of Medical Quality 2007;22:351-382.
 

Comparison of Indicators for a Primary Care Medical Home Between Children With Autism or Asthma and Other Special Health Care Needs: National Survey of Children's Health
Brachlow et al.
Arch Pediatr Adolesc Med 2007;161:399-405.
ABSTRACT | FULL TEXT  

Attitudes and Current Practice of Primary Care Physicians in Acute Stroke Management
Roebers et al.
Stroke 2007;38:1298-1303.
ABSTRACT | FULL TEXT  

Regional Variations in Health Care Intensity and Physician Perceptions of Quality of Care
Sirovich et al.
ANN INTERN MED 2006;144:641-649.
ABSTRACT | FULL TEXT  

Comparison of a spatial approach with the multilevel approach for investigating place effects on health: the example of healthcare utilisation in France
Chaix et al.
J. Epidemiol. Community Health 2005;59:517-526.
ABSTRACT | FULL TEXT  

The Essential Role of Generalists in Health Care Systems
Ferrer et al.
ANN INTERN MED 2005;142:691-699.
ABSTRACT | FULL TEXT  

Continuity of Care: Process or Outcome?
Christakis
Ann Fam Med 2003;1:131-133.
FULL TEXT  

Primary Care Medicine in Crisis: Toward Reconstruction and Renewal
Moore and Showstack
ANN INTERN MED 2003;138:244-247.
ABSTRACT | FULL TEXT  

From Physician to Consumer: The Effectiveness of Strategies to Manage Health Care Utilization
Flynn et al.
Med Care Res Rev 2002;59:455-481.
ABSTRACT  

Managed Care in Transition
Dudley and Luft
NEJM 2001;344:1087-1092.
FULL TEXT  

Association of Lower Continuity of Care With Greater Risk of Emergency Department Use and Hospitalization in Children
Christakis et al.
Pediatrics 2001;107:524-529.
ABSTRACT | FULL TEXT  

Balancing rationalities: gatekeeping in health care
Willems
J. Med. Ethics 2001;27:25-29.
ABSTRACT | FULL TEXT  

Primary Care in the United States -- The Best of Times, the Worst of Times
Grumbach
NEJM 1999;341:2008-2010.
FULL TEXT  

Resolving the Gatekeeper Conundrum: What Patients Value in Primary Care and Referrals to Specialists
Grumbach et al.
JAMA 1999;282:261-266.
ABSTRACT | FULL TEXT