Gatekeepers in Healthcare: Key Roles and Examples Explained

In healthcare, a gatekeeper is a professional or system that directs care efficiently by managing how patients access medical services. Gatekeepers commonly control specialist referrals and help reduce unnecessary tests and treatments. As such, they play a key role in controlling costs and improving care coordination. Gatekeepers appear in health insurance, often through primary care physicians, and in long-term care insurance via specific policy requirements. Countries like the U.S. rely on formal gatekeeping systems, while Austria largely doesn't.

What Is a Gatekeeper?

There are two definitions of the term gatekeeper. One is used to describe the role of people in the health insurance sector. The other refers to long-term care plans.

The term gatekeeper describes the person in charge of a patient’s treatment when it's used in relation to health insurance. Anyone who receives health insurance coverage in the form of a managed care plan, specifically a health maintenance organization (HMO) plan, is assigned a gatekeeper or allowed to choose one. The insured party is instructed to choose a primary care physician from a list in some cases, and that doctor becomes the patient’s gatekeeper.

A gatekeeper’s duty is primarily to manage a patient’s treatment. The gatekeeper is in charge of authorizing the patient’s referrals, hospitalizations, and lab studies. The patient contacts the gatekeeper who in turn refers the patient to doctors and specialists within the plan network when the patient falls ill or needs a referral to a specialist, 

Understanding Gatekeepers in Healthcare Systems 

The concept of a primary care physician as a gatekeeper to specialists and other medical resources is considered to be a managed care innovation in the United States. Its introduction has been accompanied by government-sponsored research in the United Kingdom into primary care referrals. This research could inform how the U.K.’s National Health Service shapes the gatekeeping function of general practitioners.

Many consider gatekeeping to be an effective way to contain costs by reducing unnecessary medical care interventions. Primary-level healthcare and affiliated tests and diagnoses are, on average, less expensive than secondary and specialty care services. Primary care physicians are considered to be better informed than their patients when it comes to knowing where and how to seek specialist care.

A 2015 report compared Austria, which lacks gatekeeping, to the United States where gatekeeping is practiced. It found that Austrian patients more frequently sought help from specialists compared with U.S. patients. The study revealed that the lack of a system for governing primary to secondary and tertiary care referrals led to the overutilization of secondary and tertiary care facilities.

Austrian patients consistently reported a high satisfaction rate with their healthcare system. The country has also increased its hospital capacity to accommodate the high influx of primary care needs.

The Challenges of Gatekeeping in Healthcare 

A study of the healthcare system in the Netherlands reported that many primary care physicians felt that they were relegated to administrators when they were placed in the position of gatekeeper.

This presented an issue because the average age of patients seen by primary care physicians was increasing and elderly and aged patients are more likely to present a plurality of medical ailments and require more robust medical care.

An elderly individual would be sent to several specialists in a traditional gatekeeping mechanism and this can be tiring, time consuming, and a potentially fragmented approach to their healthcare. An ideal gatekeeping system would embrace innovative solutions, multiple competence centers, clinics with multiple care options on site, and ambulatory care improvements.

General practitioners in the British healthcare system who are comparable to primary care physicians in the United States are compensated for their services via capitation rates and/or fee-for-service. This creates competition in the market for patients. It also creates a situation where a general practitioner could lose part of their funding if they hand patients over to a specialist too quickly.

On the other hand, a patient may feel that they've been denied access to secondary healthcare if their family doctor is too careful or too reserved with forwarding patients to specialists.

Gatekeepers in Long-Term Care Insurance

Gatekeepers are not people when it comes to long-term care. They're the requirements that must be met before an individual can receive any payouts from their long-term care insurance plan.

Most long-term care insurance policies require this type of care to be medically necessary for sickness or injury. Many companies conduct their own evaluations of whether this standard is met as a result, and they sometimes overrule patients’ doctors. Some policies require that the patient be unable to complete a certain number of daily activities on their own, such as bathing, walking, dressing, and eating.

The Bottom Line

Effective gatekeeping depends on clear, efficient communication among healthcare providers. Family doctors should be able to quickly consult specialists to confirm or rule out clinical concerns, while specialists must relay guidance for follow-up care. Strengthening these channels is necessary for healthcare gatekeeping to function smoothly.