Journal of General Internal Medicine

, Volume 14, Issue 5, pp 287–296 | Cite as

The influence of gatekeeping and utilization review on patient satisfaction

  • Eve A. Kerr
  • Ron D. Hays
  • Allison Mitchinson
  • Martin Lee
  • Albert L. Siu
Original Articles


OBJECTIVE: To examine the influence of utilization review and denial of specialty referrals on patient satisfaction with overall medical care, willingness to recommend one’s physician group to a friend, and desire to disenroll from the health plan.

DESIGN: Two cross-sectional questionnaires: one of physician groups and one of patient satisfaction.

SETTING: Eighty-eight capitated physician groups in California.

PARTICIPANTS: Participants were 11,710 patients enrolled in a large California network-model HMO in 1993 who received care in one of the 88 physician groups.

MEASUREMENTS AND MAIN RESULTS: Our main measures were how groups conducted utilization review for specialty referrals and tests, patient-reported denial of specialty referrals, and patient satisfaction with overall medical care. Patients in groups that required preauthorization for access to many types of specialists were significantly (p≤.001) less satisfied than patients in groups that had few preauthorization requirements, even after adjusting for patient and other group characteristics. Patients who had wanted to see a specialist in the previous year but did not see one were significantly less satisfied than those who had wanted to see a specialist and actually saw one (p<.001). In addition, patients who did not see a specialist when desired were more likely to want to disenroll from the health plan than patients who saw the specialist (40% vs 18%, p≤.001) and more likely not to recommend their group to a friend (38% vs 13%, p≤.001).

CONCLUSIONS: Policies that limited direct access to specialists, and especially denial of patient-desired referrals, were associated with significantly lower patient satisfaction, increased desire to disenroll, and lower likelihood of recommending the group to a friend. Health plans and physician groups need to take these factors into account when designing strategies to reduce specialty care use.

Key words

patient satisfaction access to specialists gate-keeping utilization management managed care 


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Copyright information

© Society of General Internal Medicine 1999

Authors and Affiliations

  • Eve A. Kerr
    • 1
    • 2
  • Ron D. Hays
    • 3
    • 4
  • Allison Mitchinson
    • 1
  • Martin Lee
    • 5
  • Albert L. Siu
    • 6
  1. 1.the Center for Practice Management and Outcomes ResearchVA Medical CenterAnn Arbor
  2. 2.the Department of Internal MedicineUniversity of MichiganAnn Arbor
  3. 3.the Department of MedicineUCLALos Angeles
  4. 4.RANDSanta Monica
  5. 5.the Center for the Study of Healthcare Provider BehaviorVA Medical CenterSepulveda
  6. 6.the Mount Sinai School of MedicineNew York

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