Gatekeeper: a health care professional, usually a primary care physician or a physician extender, who is the patient's first contact with the health care system and triages the patient's further access to the system.
US healthcare is so expensive in part because we overuse specialists, who not only charge a lot more than non-specialists but tend to order unnecessary diagnostic tests and over-treat. One way other developed countries keep their healthcare costs down is by using gatekeepers to control access to specialists. Gatekeepers are usually primary care physicians in internal medicine, family medicine or pediatrics but some countries also allow "physician extenders" like nurse practitioners to assume the primary care gatekeeping role.
The Commonwealth Fund recently released a report comparing the healthcare systems of several countries. The following table is based on this report:
As the table shows, about half of these countries require gatekeepers for specialist referral. Others have voluntary or partial gatekeeper systems. Those without gatekeepers discourage over-reliance on specialist care through financial disincentives, such as requiring higher co-pays for medical appointments without a referral. Most of these countries also set provider fees or budgets to limit over-testing and over-treatment.
The US is the outlier. While some HMOs, like Kaiser, use gatekeepers, the practice is not widespread in the private sector. Private medical professionals often set or negotiate their own fees, unless they're salaried or treating Medicare patients. However, salaried physicians in the US still do rather well for themselves because many belong to profit-sharing medical practices that are unconstrained by government-imposed budgets.
In the US, the incentives are aligned to test more, treat more, and charge more. It's no surprise that, on average, the US spends almost twice as much on its healthcare system than other developed countries. And it's no surprise that our doctors are among the highest paid in the world.
Simply shifting to a mandatory gatekeeper system would go a long way to reining in US healthcare costs. Gatekeepers keep down unnecessary procedures. Gatekeepers also earn a lot less than specialists. In the US, the annual median income for nurse practitioners is about $100K, compared to almost $200K for family and general practitioners. Compare that with the $200-$500K earned by various specialists.
Just think! If the US switched to a gatekeeping system and it became common practice for nurse practitioners to assume the gatekeeper role, the US could put a real dent in healthcare spending. Too bad the American Medical Association will hear none of it.
Next: The AMA's fight with nurse practitioners.