Resolving the gatekeeper conundrum - What patients value in primary care and referrals to specialists

Context Few data are available regarding how patients view the role of prim ary care physicians as "gatekeepers" in managed care systems. Objective To determine the extent to which patients value the role of their primary care physicians as first-contact care providers and coordinators o f referrals, whether patients perceive that their primary care physicians i mpede access to specialists, and whether problems in gaining access to spec ialists are associated with a reduction in patients' trust and confidence i n their primary care physicians. Design, Setting, and Patients Cross-sectional survey mailed in the fall of 1997 to 12 707 adult patients who were members of managed care plans and re ceived care from 10 large physician groups in California. The response rate among eligible patients was 71%. A total of 7718 patients (mean age, 66.7 years; 32% female) were eligible for analysis. Main Outcome Measures Questionnaire items addressed 3 main topics: (1) pati ent attitudes toward the first-contact and coordinating role of their prima ry care physicians, (2) patients' ratings of their primary care physicians (trust and confidence in and satisfaction with), and (3) patient perception s of barriers to specialty referrals. Referral barriers were analyzed as pr edictors of patients' ratings of their physicians. Results Almost all patients valued the role of a primary care physician as a source of first-contact care (94%) and coordinator of referrals (89%). De pending on the specific medical problem, 75% to 91% of patients preferred t o seek care initially from their primary care physicians rather than specia lists. Twenty-three percent reported that their primary care physicians or medical groups interfered with their ability to see specialists. Patients w ho had difficulty obtaining referrals were more likely to report low trust (adjusted odds ratio [OR], 2.7; 95% confidence interval [CI], 2.1-3.5), low confidence (OR, 2.2; 95% CI, 1.6-2.9), and low satisfaction (OR, 3.3; 95% CI, 2.6-4.2) with their primary care physicians. Conclusions Patients value the first-contact and coordinating role of prima ry care physicians. However, managed care policies that emphasize primary c are physicians as gatekeepers impeding access to specialists undermine pati ents' trust and confidence in their primary care physicians.