Abstract
Since the mid-1980s, health maintenance organizations (HMOs) have grown rapidly in the United States. But despite initial successes in constraining health care costs, they have come under increasing criticism for their restrictive practices. This suggests that, to remain viable, HMOs must change their behavior. Yet few studies offer empirical evidence on the matter. The present study investigates one cost-containment mechanism often associated with HMOs: the assignment of primary care physicians as gatekeepers (who, among other things, monitor patients’ use of specialist physicians). In particular, we estimate the effect of physician-HMO involvement on the percentage of HMO patients for whom physicians serve as gatekeepers. We examine this relationship over two time periods: 2000–2001 and 2004–2005. Because physicians can choose whether and to what extent they participate in HMOs, we employ instrumental variables (IV) estimation to correct for the endogeneity of the HMO measure. Although the single-equation estimates suggest that HMO assignment of physician gatekeepers diminished modestly over time, the endogeneity-corrected estimates show no change between the two time periods. Thus, one major tool used by HMOs to constrain health care costs—the physician gatekeeper—has not declined even in a period of backlash against managed care.
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Albertson G.A., Lin C., Kutner J., Schilling L.M., Anderson S.N., Anderson R.J. (2000) Recognition of patient referral desires in an academic managed care plan: Frequency, determinants, and outcomes. Journal of General Internal Medicine 15(4): 242–247. doi:10.1111/j.1525-1497.2000.02208.x
Baker L.C., Corts K.S. (1996) HMO penetration and the cost of health care: Market discipline or market segmentation?. American Economic Review, papers and proceedings 86(2): 389–394
Blendon R.J., Brodie M., Benson J.M., Altman D.E., Levitt L., Hoff T., Hugick L. (1998) Understanding the managed care backlash. Health Affairs 17(4): 80–94. doi:10.1377/hlthaff.17.4.80
Bodenheimer T. (2006) Primary care—will it survive?. The New England Journal of Medicine 355(9): 861–864. doi:10.1056/NEJMp068155
Bodenheimer T., Lo B., Casalino L. (1999) Primary care physicians should be coordinators, not gatekeepers. Journal of the American Medical Association 281(21): 2045–2049. doi:10.1001/jama.281.21.2045
Center for Studying Health System Change. (2003). Community tracking study physician survey 2000–2001 methodology report. Center for Studying Health System Change, Technical publication no. 38. Retrieved Aug 30, 2008, from http://www.hschange.org/CONTENT/570/570a.pdf
Cutler, D. M., & Sheiner, L. (1997). Managed care and the growth of medical expenditures. National Bureau of Economic Research (NBER). Working paper W6140.
Cutler D.M., Zeckhauser R.J. (2000) The anatomy of health insurance. In: Culyer A.J., Newhouse J.P. (eds) Handbook of health economics (Vol. 1A). North Holland, Amsterdam, pp 563–643
Delnoij D., Van Merode G., Paulus A., Groenewegen P. (2000) Does general practitioner gatekeeping curb health care expenditure?. Journal of Health Services Research and Policy 5(1): 22–26
Draper D.A., Hurley R.E., Lesser C.S., Strunk B.C. (2002) The changing face of managed care. Health Affairs 21(1): 11–22. doi:10.1377/hlthaff.21.1.11
Enthoven A.C., Singer S.J. (1998) The managed care backlash and the task force in California. Health Affairs 17(4): 95–110. doi:10.1377/hlthaff.17.4.95
Fang H., Rizzo J.A. (2008) The changing role of managed care on physician financial incentives. The American Journal of Managed Care 14(10): 653–660
Fang, H., & Rizzo, J. A. (2009). Managed care and physicians’ perceptions of drug formulary use. The American Journal of Managed Care forthcoming.
Feldman D.S., Novack D.H., Gracely E. (1998) Effects of managed care on physician-patient relationships, quality of care, and the ethical practice of medicine. Archives of Internal Medicine 158(15): 1626–1632. doi:10.1001/archinte.158.15.1626
Glied S.A. (2000) Managed care. In: Culyer A.J., Newhouse J.P. (eds) Handbook of health economics, (Vol. 1A). North Holland, Amsterdam, pp 707–753
Goldman D.P. (1995) Managed care as a public cost-containment mechanism. The Rand Journal of Economics 26(2): 277–295. doi:10.2307/2555917
Grumbach K. (1999) Primary care in the United States—the best of times, the worst of times. The New England Journal of Medicine 341(26): 2008–2010. doi:10.1056/NEJM199912233412611
Grumbach K., Selby J.V., Damberg C., Bindman A.B., Quesenberry C., Truman A., Uratsu C. (1999) Resolving the gatekeeper conundrum: What patients value in primary care and referrals to specialists. Journal of the American Medical Association 282(3): 261–266. doi:10.1001/jama.282.3.261
Haas J.S., Phillips K.A., Baker L.C., Sonnebom D., McCulloch C.E. (2003) Is the prevalence of gatekeeping in a community associated with individual trust in medical care. Medical Care 41(5): 660–668. doi:10.1097/00005650-200305000-00013
Halm E.A., Causino N., Blumenthal D. (1997) Is gatekeeping better than traditional care?. A survey of physicians’ attitudes. Journal of the American Medical Association 278(20): 1677–1681. doi:10.1001/jama.278.20.1677
Jancin B. (2006) Primary care gatekeeper model tied to poor CVD outcomes. Family Practice News 36(8): 8
Kazel, R. (2003). Managed care easing gatekeeper hassles. American Medical News(January), 20. Retrieved Aug 30, 200, fromhttp://www.ama-assn.org/amednews/2003/01/20/bil20120.htm. Published by American Medical Association.
Kerr E.A., Hays R.D., Mitchinson A., Lee M., Siu A.L. (1999) The influence of gatekeeping and utilization review on patient satisfaction. Journal of General Internal Medicine 14(5): 287–296. doi:10.1046/j.1525-1497.1999.00336.x
Lin C., Albertson G., Price D., Swaney R., Anderson S., Anderson R.J. (2000) Patient desire and reasons for specialist referral in a gatekeeper-model managed care plan. The American Journal of Managed Care 6(6): 667–678
Manson A. (1995) Why primary care physicians should not be restrictive gatekeepers. Journal of General Internal Medicine 10(3): 145–146. doi:10.1007/BF02599670
Marquis S.M., Rogowski J.A., Escarce J.J. (2004) The managed care backlash: Did consumers vote with their feet?. Inquiry 41(4): 376–390
Mays G.P., Hurley R.E., Grossman J.M. (2003) An empty toolbox? Changes in health plans’ approaches for managing costs and care. Health Service Research 38(1.2): 375–393
Miller R.H., Luft H.S. (2002) HMO plan performance update: An analysis of the literature, 1997’2001. Health Affairs 21(4): 63–86. doi:10.1377/hlthaff.21.4.63
Newhouse J.P. (1996) Reimbursing health plans and health providers: Efficiency in production versus selection. Journal of Economic Literature 34(3): 1236–1263
Phillips K.A., Hass J.S., Liang S., Baker L.C., Tye S., Kerlikowske K., Sakowski J., Spetz J. (2004) Are gatekeeper requirements associated with cancer screening utilization?. Health Services Research 39(1): 153–178. doi:10.1111/j.1475-6773.2004.00220.x
Robinson J.C. (2001) The end of managed care. Journal of the American Medical Association 285(20): 2622–2628. doi:10.1001/jama.285.20.2622
Robinson J.C., Casalino L.P. (1995) The growth of medical groups paid through capitation in California. The New England Journal of Medicine 333(25): 1684–1687. doi:10.1056/NEJM199512213332506
Starfield B. (1992) Primary care: Concept, evaluation, and policy. Oxford University Press, United States
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Fang, H., Liu, H. & Rizzo, J.A. Has the use of physician gatekeepers declined among HMOs? Evidence from the United States. Int J Health Care Finance Econ 9, 183–195 (2009). https://doi.org/10.1007/s10754-009-9060-8
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DOI: https://doi.org/10.1007/s10754-009-9060-8