Gatekeeping: Good or Bad, but Never Indifferent

To the Editor.—As a primary care internist and geriatrician I care both for patients enrolled in managed care organizations (MCOs) and for those insured under traditional Medicare or commercial insurance. I have known medicine before Medicare, with Medicare, and now with managed care. Thus, the article "Is Gatekeeping Better Than Traditional Care?"¹ had special relevance for me. In my opinion, gatekeeping has the following positive aspects: (1) I have total responsibility for my decision to use other health care workers, such as visiting nurses and social workers. I can provide nonepisodic care to these patients. (2) I can avoid overutilization of specialists and polypharmacy. (3) Many of my new managed care patients have never had access to modern medical care that is preventive and not episodic. (4) Managed care organizations have access to physicians' office medical records, review these, and can emphasize quality assurance issues, since "those that pay the bills, set the rules." Once yearly, my office records are checked by the MCO. Some of the suggestions are nitpicky, but some have been helpful. However, the use of practice parameters that could have a significant effect on medical practice have not been implemented, ie, the use of warfarin sodium in patients with atrial fibrillation. In the previous system, there was no quality control or accountability by review of office records unless legal problems arose. (5) Billing paperwork is eliminated by capitation.