Primary care physicians should be coordinators, not gatekeepers

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, returni ng to the pre-managed care model of uncoordinated open access to specialist s is a poor solution. The primary care model should be retained, but PCPs s hould be transformed from gatekeepers into coordinators of care, in which t he goal of the PCP is to integrate both primary and special?, care to impro ve quality. Changes in the PCP's daily work process, as well as the referra l and payment processes, need to be implemented to reach this goal. This mo del would eliminate the requirement that referrals to specialists be author ized 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 special ists. Budgeting specialists should control excess costs that might be creat ed by the elimination of the primary care gatekeeper. Pilot projects are ne eded to test and refine this model of PCP as coordinator of care.