Gatekeeping and referral of children and adolescents to specialty care

Objective. In this study we examined how gatekeeping arrangements influence referrals to specialty care for children and adolescents in private and Me dicaid insurance plans. Design/Participants. We conducted a prospective study of office visits (n = 27 104) made to 142 pediatricians in 94 practices distributed throughout 3 6 states in a national primary care practice-based research network. During 10 practice-days, physicians and patients completed questionnaires on refe rred patients, while office staff kept logs of all visits. Physicians used medical records to complete questionnaires for a subset of patients 3 month s after their referral was made. Results. Gatekeeping arrangements were common among children and adolescent s with private (57.8%) and Medicaid (43.3%) insurance. Patients in gatekeep ing plans were more likely to be referred with private (3.16% vs 1.85% visi ts referred) and Medicaid (5.39% vs 3.73%) financing. Increased parental re quests for specialty care among gatekeeping patients did not explain the in creased referral rate. Physicians' reasons for making the referral were sim ilar between the two groups. Physicians were less likely to schedule an app ointment or communicate with the specialist for referred patients in gateke eping plans. However, rates of physician a awareness that a specialist visi t occurred and specialist communication back to pediatricians did not diffe r between the two groups 3 months after the referrals were made. Conclusions. Gatekeeping arrangements are common among insured children and adolescents in the United States. Our study suggests that gatekeeping arra ngements increase referrals from pediatricians' offices to specialty care a nd compromise some aspects of coordination.