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Letters |

Gatekeeping: Good or Bad, but Never Indifferent

Debra Feldman, MD
JAMA. 1998;279(12):908-910. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-12-jbk0325.
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To the Editor.—The attitude survey by Dr Halm and colleagues1 provided important results about the gatekeeping aspect of managed care, documenting physicians' attitudes on patient care, administrative, and utilization issues. However, the summary qualitative judgment score, presented to support the conclusion that 72% of respondents felt gatekeeping was better than or comparable to traditional care arrangements, is misleading. This score was based on the respondents' views on the overall effect of the 2 systems on quality and cost. Some physicians may believe that other factors, along with quality and cost, contribute to their final evaluation of gatekeeping. The survey itself provides a possible example. A majority of physicians felt that gatekeeping caused increased administrative work. Many physicians would view the combination of same cost, same quality, and increased administrative work as summing up to a negative assessment of gatekeeping, as opposed to a neutral view that would have been attributed to their use of the summary qualitative judgment score. If the authors wanted to supply an overall assessment of physicians' views on gatekeeping compared with traditional systems, they should have asked the survey group this question directly. As it is, the authors may have significantly misrepresented the views of physicians on gatekeeping.

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