Ferris T G, Chang Y, Blumenthal D, Pearson S D
Institute for Health Policy, Division of General Internal Medicine, Massachusetts General Hospital-Partners Health Care System and Harvard Medical School, Boston, USA.
N Engl J Med. 2001 Nov 1;345(18):1312-7. doi: 10.1056/NEJMsa010097.
Gatekeeping refers to the prior approval of referrals to specialists by a primary care physician. Although many health plans view gatekeeping as an essential tool for controlling costs and coordinating care, many patients and physicians object to it.
On April 1, 1998, Harvard Vanguard Medical Associates, a large, multispecialty, capitated group practice previously known as Harvard Community Health Plan, eliminated a gatekeeping system that had been in place for over 25 years. We determined the effects of opening access to specialists on visits to primary care physicians and specialists by adults. In randomly selected cohorts of 10,000 members each, we analyzed visits during 6-month periods for the 3 years before and 18 months after gatekeeping was eliminated.
Adults visited a primary care physician an average of 1.21 times and 1.19 times per six-month period before and after the elimination of gatekeeping, respectively (P=0.05); the average number of visits to a specialist was 0.78 per six-month period both before and after its elimination (P=0.35). There was little change in the percentage of visits to specialists included in the analysis as a proportion of all visits (39.1 percent before the elimination of gatekeeping and 39.5 percent afterward). The percentage of first visits to specialists as a proportion of all visits to specialists included in the analysis increased from 24.7 to 28.2 percent (P<0.001). There were small increases in the numbers of visits to orthopedists and physical or occupational therapists. The proportion of visits to specialists for low back pain that were new consultations increased from 26.6 to 32.9 percent (P=0.01).
In a capitated, multispecialty group practice, we found little evidence of substantial changes in the use of specialty services by adults in the first 18 months after the elimination of gatekeeping.
守门制度是指由初级保健医生预先批准转诊至专科医生。尽管许多健康计划将守门制度视为控制成本和协调医疗的重要工具，但许多患者和医生对此表示反对。
1998年4月1日，哈佛先锋医疗联盟，一个大型的多专科、按人头付费的团体医疗实践机构，此前称为哈佛社区健康计划，取消了已实施超过25年的守门制度。我们确定了取消对专科医生的转诊限制后，成人对初级保健医生和专科医生就诊的影响。在每组随机抽取的10000名成员中，我们分析了取消守门制度前3年和取消后18个月期间每6个月的就诊情况。
取消守门制度前后，成人每6个月平均就诊初级保健医生的次数分别为1.21次和1.19次（P = 0.05）；取消守门制度前后，每6个月平均就诊专科医生的次数均为0.78次（P = 0.35）。分析中就诊专科医生的次数占所有就诊次数的比例变化不大（取消守门制度前为39.1%，之后为39.5%）。分析中首次就诊专科医生的次数占所有就诊专科医生次数的比例从24.7%增至28.2%（P < 0.001）。骨科医生以及物理治疗师或职业治疗师的就诊次数略有增加。因腰痛就诊专科医生时新咨询的比例从26.6%增至32.9%（P = 0.01）。
在一个按人头付费的多专科团体医疗实践中，我们发现几乎没有证据表明取消守门制度后的头18个月里成人使用专科服务的情况有实质性变化。
