Bodenheimer T, Lo B, Casalino L
Department of Family and Community Medicine, University of California at San Francisco School of Medicine, USA.
JAMA. 1999 Jun 2;281(21):2045-9. doi: 10.1001/jama.281.21.2045.
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, returning to the pre-managed care model of uncoordinated open access to specialists is a poor solution. The primary care model should be retained, but PCPs should be transformed from gatekeepers into coordinators of care, in which the goal of the PCP is to integrate both primary and specialty care to improve quality. Changes in the PCP's daily work process, as well as the referral and payment processes, need to be implemented to reach this goal. This model would eliminate the requirement that referrals to specialists be authorized 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 over-referral and underreferral to specialists. Budgeting specialists should control excess costs that might be created by the elimination of the primary care gatekeeper. Pilot projects are needed to test and refine this model of PCP as coordinator of care.
初级保健守门制度中，初级保健医生（PCP）的目标是减少患者转诊至专科医生处，从而降低成本，但这并非一个适宜行医的充分体系。然而，回归到未协调的开放专科就诊的预管理式医疗模式也并非良策。初级保健模式应予以保留，但初级保健医生应从守门人转变为医疗协调员，其目标是整合初级保健和专科保健以提高质量。为实现这一目标，需要对初级保健医生的日常工作流程以及转诊和支付流程进行变革。这种模式将消除由初级保健医生或管理式医疗组织授权转诊至专科医生的要求。例如，需要经济激励措施来鼓励初级保健医生对复杂病例进行管理，并抑制过度转诊和转诊不足的情况。预算专家应控制因取消初级保健守门人可能产生的额外费用。需要开展试点项目来测试和完善这种将初级保健医生作为医疗协调员的模式。
