SECOND OPINIONS : I Am a Physician--Don’t Call Me a ‘Gatekeeper’ : Insurers pressure primary-care providers to keep services, and therefore costs, at a minimum. If the industry is on a mission to cut waste, it should take a hard look at itself.
Primary-care physicians are often referred to as gatekeepers nowadays, especially by insurance companies. As gatekeepers, we are viewed as the people who let patients into the medical system or keep them out.
I have used the term myself. I even wrote an article a couple of years ago for Managed Care magazine entitled “The Ideal Gatekeeper.”
In theory, I argued, the ideal gatekeeper is best for the patient and best for society but not for the insurance industry. Ideal gatekeeping would eat into the industry’s profits. Managed-care committees working for the insurance industry dictate what the keeper can allow through the gate. Therefore, the primary physician cannot permit everything that constitutes ideal gatekeeping.
I was preparing recently for a television round-table discussion of HMOs and managed care, and it struck me that I am not a gatekeeper. I don’t want to be known as a gatekeeper. My patients don’t want me to be a gatekeeper.
I don’t know why nobody has openly stated what a demeaning expression gatekeeper is. I believe that the title benefits no doctor and should be dropped from the medical parlance.
The word implies that the job of the person guarding that gate is to keep us from getting to whatever is on the other side. The gatekeeper guards the entrance to specialty care and expensive procedures and thereby saves money.
I do not want to be the insurance industry’s gatekeeper. I am a primary-care physician, trained to provide diagnostic and treatment services to patients. Diagnosis and treatment at that level are generally quite cost-effective. There is usually a great deal of satisfaction and loyalty at this level of care on the part of both patient and doctor. Lifelong relationships are common. The surest way to wreck that precious atmosphere is to be perceived as a gatekeeper.
Primary physicians can handle most uncomplicated diagnostic procedures and treatments. Almost all preventive medicine is done by the primary physician. Many infectious diseases, simple orthopedics, wound repair and some surgeries are done at the primary level. Wise primary physicians know their limits and when to refer their patients to appropriate specialists.
Primary physicians often develop a network of trustworthy specialists who serve not only their patients but the doctor’s own family. What can be more encouraging to patients than the knowledge that their doctor trusts the specialists enough to send his or her own family to them?
For patients to be best served, there must be free choice and easy access. The gatekeeping system usually provides neither. Furthermore, there are often delays in the referral process as well as a layer of burdensome paperwork.
My patients do not want me to be a gatekeeper, they want me to be a gate opener and an expediter. I didn’t spend all those years in school and training to stand between my patients and the specialty care they need.
I realize that it’s important to practice in a cost-effective manner. The assets of our country’s health care system are limited. A physician’s services should provide maximum value to the patient.
The insurance industry uses too much of the premium dollar for administration, marketing, huge executive salaries and corporate profits--and too little for patient care.
The health-delivery system must be capable of providing care for every man, woman and child in this country. It must safeguard medical research and the education of future care-givers. The insurance industry is doing neither. The health-delivery system must provide efficient utilization review and diligent fraud detection, without wasting patient care funds on unnecessary administration and paperwork.
Rep. James McDermott (D-Wash.), a physician, points out that Medicare operates on a 2 1/2% administrative overhead. Insurance industry overhead has been reported as high as 30%. McDermott advocates a single-payer health care system. In order to preserve their very profitable turf, insurers try to frighten us into believing that this is socialized medicine. It is not!
In a single-payer system, the care givers, hospitals and providers would be as they are now. The savings achieved would pay for patient care rather than competitive marketing, corporate profits and obscene executive salaries. Without the insurance industry’s “gatekeepers,” patients and their doctors will once again have free choice and easy access to care.
