Primary care gatekeeping and referrals: patient’s view on the family physician role

Abstract

An adequate primary healthcare system substantially determines quality of population health and effective spending of healthcare resources. The family physician serving as a ‘gatekeeper’ can make judicious decisions about the appropriate use of medical services. The goal of this study was to find out patients’ characteristics, preferences and behavior in regards to the role of the family physician as the gatekeeper in The Republic of Georgia. As part of a cross-sectional quantitative study, respondents were interviewed using a structured questionnaire. Majority of the respondents (53.7%, n=245) had a permanent family physician, but were not satisfied with a level of family physician’s professionalism (56.6%, n=258) and preferred self-referral to specialists (55%, n=253). Only 19.5% (n=89) referred to specialists upon family physician’s advice who would coordinate all services and 23% (n=103) have used both family physicians and self-referral. Private health insurance companies were more interested in implementing cost reducing mechanisms rather than the Social Service Agency (which is responsible for Universal Health Care Program). Study results demonstrated that attitudes of different demographic groups of population towards the ways of referral to specialists differ from each other. A certain part of patients preferred referring to family physicians who would coordinate all required medical services and be a sole agent protecting their interests. The study demonstrated that beneficiaries of the private health insurance prefer referring to specialists through their family physicians. It is due to the fact that private health insurance companies were more concerned with establishing cost reduction mechanisms rather than the beneficiaries of UHCP. Such a mechanism implies increasing a role of family physicians, i.e. the gatekeepers of the healthcare system. The model of gatekeeper has more benefits in regards to response to the patient’s needs, improvement of the medical service coordination and cost reduction. Such approach fits the key primary health values more, it accentuates the key role of family physicians in the process of treatment and the importance of confidence in the patient- physician relationship as well as responsiveness to the individual patient needs. In order to widely implement the gatekeeper model within the UHCP, each beneficiary should have a permanent family physician who would ensure continuous and comprehensive medical service provision. It is advisable to raise the level of skills of family physicians, to develop a continuous medical education, as the highly skilled physicians will enjoy more confidence among patients that in turn will increase the rate of referral to them. According to our study some beneficiaries preferred their family physician to co-ordinate their care and referral to specialists when needed, while others preferred self-referral. Therefore, implementing a flexible voluntary model of gatekeepers may be a recommended policy. The flexible voluntary model of gatekeepers means that the UHCP should explicitly offer all options and encourage their members to choose the option which fits their preferences: self-referral, gatekeeping or coordinated care with self-referral. A voluntary choice of the gatekeeper model is acceptable both for physicians and for patients since it has no negative effect on the relations between physicians and patients, plus it is responsive to patients’ needs. It can be assumed that implementing gatekeeping voluntarily will be acceptable to physicians, because a possible detrimental effect on patient relations, will not exist in a voluntary model. Furthermore, a voluntary choice increases even more a responsibility of the family physician as he/she ensures provision of comprehensive medical services, including having control over the course of treatment.