Advantages Of Gatekeeping In The Healthcare System

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Advantages Of Gatekeeping In The Healthcare System

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However, there is little evidence suggesting that gatekeeping is more beneficial than direct access in terms of patient- and health-related outcomes. Aim: To establish the impact of GP gatekeeping on quality of care, health use and expenditure, and health outcomes and patient satisfaction. Design and setting: A systematic review. Two authors independently screened search results and assessed the quality of studies. Results: Electronic searches identified studies after removing duplicates , of which 25 met the inclusion criteria. Even if your primary care provider is in one city and your specialist is in another and with a different company, you can still instantly access your data so that a treatment plan can be developed.

It keeps families together. Managing health care requires the development of a relationship between patient and provider. Because patients can choose their providers within a network, it is much easier to have an entire household or family see the same doctor. There is a certain guarantee of care within the network. Managed care networks require their providers to pass various accreditation processes so that patient care can be provided as effectively as possible. Although there is sometimes a push to hire younger, more inexperienced providers as a cost-savings measure, the accreditation mandate still provides patients with the peace of mind knowing that there must be at least a certain minimum guarantee for the care that they need.

Prescription management is much easier. Many networks work with pharmaceutical agencies to ensure that needed prescriptions are available and affordable to those who need them. This process simplifies the refill process and, in some instances, can even lower costs. It limits care access for those who do not have insurance or provider coverage. Many people in this situation are forced to go to an emergency room for care because it cannot be denied there.

Finding a provider in private practice is virtually impossible, even with sliding scale fee schedules, when there is an inability to pay for health care services. The rules of managed care are extremely rigid. In a system of managed care, your options are very limited when it comes to choosing your own doctor. People are forced to advocate for themselves. Because referrals are necessary for advanced levels of care, especially if they must go outside the network, people must be extremely proactive and aggressive as they advocate for their health care. They must follow-up with their insurance provider to ensure out-of-network procedures are authorized.

Scheduling, appointment follow-ups, file reviews, and treatment plans require intense personal attention to make sure the best possible outcome can be achieved. As the same manager in the district hospital argued, some who preferred to stay at primary care facilities were happy that way, because of a light workload and a steady income—less stressful compared to hospitals. Related to this was the increasing hospital visits associated with the hospital incentive structure linked with revenue generation. The hospitals also used such revenue to build up their advantage in equipment and infrastructure.

In short, the comprehensive structural advantage of the hospital fed back to its functional advantage in that it attracted ever more patients. The advantage of hospitals also fed back to the policy making process. In other words, the opposition from the interests related to hospitals were challenging the sustainability of the gatekeeping pilot in its current design. Indeed, the municipal NCMS administrator was considering replacing the pilot programme by moving the fundholding role i. Patients found primary care facilities to be very restrictive in services, technologies, and pharmaceuticals, and felt they received little extra benefit when they came to visit primary care facilities for referral.

The extra visits became a burden to primary care facilities, too. Will you say that is not troublesome for them? It is understandable that patients complained… They are not willing to come here to get referral. Most doctors and patients considered the policy an inconvenience, though some also acknowledged that the policy brought additional opportunities to make contact with patients. In several cases, patients went to hospitals first, and later found that they had to get a referral from primary care doctors when they tried to claim reimbursement. Furthermore, there was little integrative care arrangements e. The referral requirement thus became largely ritualistic, which added to the resentment of doctors and patients. In particular, gatekeeping hurt local elites who had more say in the political process e.

One limitation is that the study did not allow interviewees or independent experts to validate the causal loop model, which has been recommended [ 55 ]. After a failed attempt to explain an earlier draft of the CLD to some municipal policy makers, the lead author found it difficult to use the CLD as a communication tool to policy makers who had little prior training, and to explore this further was beyond the capacity of the study. The findings should therefore be seen as the understanding of the researcher, generated through a rigorous process. The approach used in this study seems to have advantages in understanding the complexity involved in shifting balance of care through interventions like gatekeeping.

The use of the WHO categorisation of health systems building blocks facilitated a systematic mapping of factors related to gatekeeping. In the study, applying the categorisation facilitated the identification of issues directly related to the mechanisms of gatekeeping such as financing e. The application of a CLD has allowed the study to bring together the separate analyses to understand the interrelationships between different factors within and across categories of building blocks. One particular advantage is related to dealing with unintended consequences of policies indirectly related to gatekeeping e. The CLD also has allowed the study to identify both local patterns of feedback loops and how these feedback loops formed a holistic picture of all the key factors related to gatekeeping.

Overall, the approach bridged analysis of the gatekeeping pilot with analysis of the system within which the gatekeeping pilot was embedded. The approach brought into the qualitative evaluation of gatekeeping the three dimensions of interrelationships, perspectives and boundaries, highlighted in the systems literature [ 43 ]. It revealed the richness of interrelationships among different factors within the health system that were directly or indirectly related to gatekeeping functioning, reflected the multiple perspectives of different groups of stakeholders, and encouraged a deeper understanding of the boundaries by highlighting the linkages between the intervention and the system, as well as by examining unintended consequences of the gatekeeping pilot.

Furthermore, the approach of qualitative systems analysis developed in this study was explicit and transparent. A systematic review of the recent use of system science and systems thinking for public health suggested that studies using systems modelling methods should make the formulation of models in this case a CLD explicit enough for readers to judge the rigour of the studies or to repeat the process [ 55 ].

The complicated process and lack of transparency of interim stages made causal loop analysis prone to issues regarding accountability. The danger of misunderstanding the system based on a model with suboptimal rigour is also amplified by the assumed interconnectedness of the factors. However, guidance on how to rigorously develop CLDs based on qualitative methods and data have been lacking.

This study has established an example of a transparent and rigorous approach to qualitative systems analysis of a complex health systems intervention. The study has presented the first evidence on the intended and actual functioning of gatekeeping in a pilot in rural China. The intended supply-side incentive on treating a greater number of patients at local facilities did not seem to have functioned as expected, as the salary policy was too rigid with a level of pay too low to either attract or incentivise gatekeeping-related clinical work. On the demand side, a large number of patients appeared to be going through primary care reluctantly to get referral in a generally ritualistic process.

The implementation of the approach of gatekeeping in the studied pilot led to dissatisfaction of both doctors and patients. This contradicts a patient survey done in Shenzhen [ 56 ] that showed stated willingness of local residents to accept community health centres as gatekeepers. Besides public resentment, potential adverse effects included delay of diagnosis or misdiagnosis. The study did not investigate this issue directly, but the weak primary care capacity suggested that this would be hard to avoid [ 34 ], if a significant number of patients relied on the primary care providers.

Furthermore, given the different capacity of primary care facilities and hospitals, implementing gatekeeping only for the NCMS could potentially exacerbate inequity by restricting their access to facilities of lower service quality. The study identified three aspects that led to the sub-optimal functioning of the gatekeeping pilot. First, the weak conditions of primary care, particularly regarding the clinical skills of primary care doctors in comparison with those in hospitals, seemed to be a fundamental barrier facing the reform.

The nation-wide gap between qualifications of primary care doctors and hospital doctors was sustained over the recent decade when social health insurance coverage was extended to the whole population [ 57 ]. Therefore, it was understandable that patients in the pilot townships were not satisfied when their eligibility for direct access to ambulatory services in hospitals were taken from them. The lack of progress in reforming hospitals exacerbated the imbalance between the two sectors.

Despite reform in primary care, the inflationary incentive structure in hospital care remained unchanged. Hospitals were systematically absorbing human resources, patients, and other resources, contributing to greater imbalance in the system. Hospitals particularly the district hospital in the pilot area have become increasingly the main provider of curative care and received most of the total medical expenditures.

This is corroborated by a quantitative analysis comparing nation-wide service utilization in hospitals and primary care providers in recent years [ 57 ]. The self-reinforcing nature of the imbalance between hospitals and primary care facilities could mean increasing difficulty in future reforms. Third, the effectiveness of gatekeeping was hampered by the unintended consequences related to conflicts among different priorities required of primary care development. Primary care facilities have been loaded with much aspiration for the ultimate goal of universal health coverage in low- and middle-income countries.

There coexisted multiple policy initiatives in the pilot as well as China-wide: strengthening the function of primary care facilities in curative primary care, strengthening the function of primary care facilities in preventive primary care for the increasingly prevalent non-communicable diseases, curbing over-prescription related to the previous incentive structure, and reducing pharmaceutical prices.

These intersecting reforms provided plenty of scope for clashes and inconsistences. The findings suggested challenges in changing the functions of primary care facilities, as primary care facilities have relied for years on mechanisms similar to those in the hospital sector revenue-generation, recognition of professional status focused on treating diseases, etc. The effort to strengthen chronic disease prevention e. However, it might undermine efforts to provide more and better curative care at primary care facilities, and even break down the appreciation of professional status and competence of primary care practitioners by both patients and colleagues.

The essential drug policies, which seemed to have unintendedly led to limited access to pharmaceuticals at primary care facilities, also restricted the range of services available at this level. Previous studies have suggested these were common challenges facing primary care facilities in China [ 6 ], though our study further elucidated the underlying dynamics. However, most of the policies involved with the exception of gatekeeping were made nationally and implemented nation-wide. The issue of structural and functional imbalance between hospitals and primary care facilities has been a nation-wide phenomenon as reflected in the references cited above from nation-wide studies.

On the basis of what Yin defined as analytical generalization, which builds generalization upon theoretical comparability [ 58 ], this first qualitative evaluation about a pioneer gatekeeping pilot is relevant to comparable settings in rural China, which faces essentially similar challenges. Overall, the study has suggested that the gatekeeping pilot failed to alter the dynamics involved in an increasingly imbalanced local health system. If scaled up and strictly adopted in settings with weak primary care, gatekeeping of the kind implemented in the pilot could lead to other undesirable outcomes. These might include public resentment and other unintended consequences in equity and quality of care e. Gatekeeping pilots need to be attempted in areas with better primary care conditions, and combined with supporting policies, including collaboration with hospitals, perhaps selectively for specific health problems.

More broadly, the difficulties facing primary care strengthening in rural settings also indicated the risks related to a lack of appreciation of the complexity involved in primary care functioning in reality and the potential and manifested conflicts among multiple reform priorities, as well as lack of progress in hospital reform. Measures to strengthen primary care should be careful not to change too fast the function of doctors without managing professional aspirations, while they should also be bold enough to promote consistent and harmonised changes. The converging point of primary-care-related policies in rapid and multidimensional transition on multiple fronts should be centred on the people at the core of primary care delivery.

What is needed seems to be a systemic effort to reconstruct primary care professionals. Such efforts should not be stand-alone policies such as training general practitioners, but a human-centric reform expanded to cover the clarification of organizational functions of primary care facilities with development of primary care teams, adequate financing of primary care, professional development, and other supporting elements including access to technologies and medicines.

In addition, reform of hospitals to constrain their profit-orientated expansion should also be pushed forward. In this paper, we have presented a qualitative systems analysis of how gatekeeping functioned under constraints in a pilot in rural China. The study has revealed the ineffectiveness of gatekeeping in shifting the balance towards primary care. The current salary policy was too rigid with a level of pay too low to either attract or incentivise gatekeeping-related clinical work. The study has suggested a number of underlying systems factors that restricted the functioning of gatekeeping in the pilot area. The weakness of primary care capacity particularly in terms of human resources lay at the heart of ineffective gatekeeping.

Primary care facilities were also trapped in vicious cycles. Particularly dangerous was the phenomenon that the primary care doctors were losing patient trust and professional aspirations. Unintended consequences of a number of concurrent policies also impeded strengthening of primary care functioning. Strict regulation on pharmaceuticals and the technological imbalance between primary care and hospitals limited the medicines and technologies available to primary care facilities.

The delayed reform of perverse hospital incentives also contributed to the barriers to successful functioning of gatekeeping. The findings imply that two kinds of logic are needed in formulating policies to improve the underlying conditions of gatekeeping. On the one hand, the vicious cycles that primary care facilities were facing requires bold and timely measures. In particular, it seems necessary and urgent to elevate the competence of primary care doctors, who should also be provided with career prospects. Hospital reform should also be pushed forward to tame their profit orientation. On the other hand, the findings suggest caution on reforms regarding primary care. Rather than shuffling of functions, the policy makers should design reform in which primary care doctors can consolidate their professional standing and the trust of patients and colleagues.

There should also be mechanisms to learn from experience and make timely policy adjustments. The study has demonstrated the use of a qualitative systems approach to study a complex health system intervention, and identified the limitations and value of the approach. Further research may build on the transparency demonstrated in this study and the approach to model construction should be recorded and reported clearly.

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