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Letters |

Gatekeeping: Good or Bad, but Never Indifferent—Reply

Ethan A. Halm, MD, MPH; David Blumenthal, MD, MPP; Nancyanne Causino, EdD
JAMA. 1998;279(12):908-910. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-12-jbk0325.
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In Reply.—The comments of Drs Finestone, Feldman, Beasley, and Volpintesta are representative of the heated debate regarding the goals and consequences of gatekeeping. Opponents tend to emphasize negative "controlling" functions (restriction of referrals, procedures, visits to specialists, and hospitalizations), and proponents tend to emphasize positive, primary care "coordinating" activities (overall knowledge of care, prevention, and avoidance of duplicative or unnecessary procedures). To shed more light than heat on this debate, we sought to collect empirical data on both potential favorable and unfavorable effects of gatekeeping on a broad range of domains of care, including administrative work, patient care dynamics, resource use, coordination, and use of preventive services, in addition to global judgments about effects on cost and quality. Feldman questions with our a priori hypothesis that the effects of gatekeeping on cost and quality were of paramount importance. We believe we are in the mainstream in emphasizing these 2 key aspects of health care.

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