The Medical Gatekeepers     9/97

by Del Meyer, MD

Should a doctor control the patient’s total care by being the Medical Gatekeeper? There has been ample negative press and staff room discussions concerning this concept. Conversely, the overlapping or duplicative services which occur when a patient sees several physicians without his prior record preceding him has driven health care costs beyond the acceptable range, giving birth to managed care.

The nonprofit HMOs (NP-HMO) such as Kaiser Permanente have always had full control of how their patients obtain medical care. The patient has one primary physician who overseas all of the patient’s care and the one chart precedes the patient to his next appointment. This full disclosure to each physicians of the entire medical team is the only way that costs can be kept under control.

Former Kaiser patients have joined For Profit HMOs (FP-HMO) because they felt the premium was cheaper or they could bypass the "gatekeeper" and go directly to a specialist. If their new personal physician was also their specialist, they were happy and costs were contained in one office. If they demanded other specialists whose necessity was not really apparent, then costs would obviously double for one consult, triple for a second consult and so on. (Two doctors each doing his own thing would generally be a 100% increase in costs, although it could be many times that.) To keep the costs down, the benefits obviously had to cost less. Since FP-HMOs took their job of cost containment (as well as other things such as profits) seriously, they put in the same controls as the Non Profit HMOs (NP-HMO) and established a "Medical Gatekeeper." This basically puts the primary care physician as the front to screen the necessity. For instance, if a patient wants to see a podiatrist to trim his toenails, and the primary care doctor observes that the degree of arthritis and deformity is not that disabling, he would not authorize a podiatric consultation. There still is not full trust since there are a number of backup procedures behind the gatekeeper to further manage costs.

Why, then, are so many physicians opposed to having one of our colleagues rather than a bureaucratk in charge? This animosity has gone so far that some insurance plans are allowing patients to see specialist without a referral. Is this appeasement, or what? As Churchill once said, appeasement is only a guarantee that the "crocodile will eat us last." This little bypass will start the cost spiral all over again and the "crocodile" will eventually eat us.

When Sam Jacobson, MD, the Physician-in-Chief of Wayne County General hospital, lost favor with the bureaucrats of Wayne County, Michigan after some 25 years in administration, he returned to the practice of medicine, our usual safety net bce (before the current era). Making rounds with him for a rotation as a medical resident was one of life’s more rewarding experiences. When asked how he could discuss the medical problems of the day so expertly, he credited 25 years of reading SCIENTIFIC AMERICAN, the best running text on biology. If he didn't know the specific name of a drug or its dose, he could still explain the concepts of therapy as few other professors.

It was his philosophical overview, however, that always struck a resonant chord in those of us who sought him out after rounds and during coffee breaks. As the Physician-in-Chief of the largest public tax supported hospital in the United States with over 6500 patients, he predicted a return of For Profit hospitals before the turn of the century. He also said that the internist would become the "non manipulative" primary practitioner who could hold his own with the deluge of sub-specialists with technology at their disposal. In other words, the internist of the future would be in charge of the patient care--his gatekeeper, if you will, so that patients would not just become subjects to be passed along through the medical system with no one in charge, sending technological costs off the charts.

Many personal physicians and especially internists have abdicated their roles. We observe good internists who do an excellent job of making a diagnosis and instituting therapy, and then diminish themselves by telling the patient, "Let me have you see a super specialist just to make sure that we haven’t missed anything." The patient returns a few weeks or months later after incurring $5,000 or $10,000 of healthcare costs, and surprise, nothing serious was missed. But a $500 evaluation did increase 1,000% or 2,000% with no useful benefit. But the patient perceives this as a benefit as he is awed by costly modern medical technology. Is it any wonder that patients are conditioned to go directly to additional specialists regardless of the need? With this doubling and tripling of costs, is it any wonder why politicians, bureaucrats, and their staffers don’t take us seriously? Why they write all kinds of rules into the lengthy laws our congressmen pass that they neither read or understand? Laws which include prison terms for our non-violent profession?

If we as specialists think that patients should have access to us without regard to what their primary care physician (PCP) think, economics will surely eliminate the vast majority of us. Then because of bureaucratic fiat only a certain type of patient that meets a certain guideline will get to us and we will have lost for our patients the freedom of an open medical practice environment. Specialists would have yet another set of guidelines to follow in giving our opinion that prevents any variation for the human individuality. The patient just never seems to fit any guideline. And if the guidelines of the PCP can be done by a PA, so can the specialist’s guidelines. After all, it just takes the ability to read at the 14th grade level.

Our profession needs to take the stand that every patient in the country should have a designated personal physician as the primary medical counselor. This could be any doctor who is willing to do just that including any specialists. There have always been general surgeons and medical sub-specialists who have done that in the past without regimentation. Every hospital admission, consultation, laboratory, x-ray, or other diagnostic test would have to be okayed by the patient’s personal physician or there would be no payment for the services. This would be a huge strike for serious cost containment. And it would put doctors in charge of American health care. Even if not perfect, it is vastly superior to the administrator or bureaucrat who looks at the bottom line first and the patient last and then only if absolutely necessary.