The Impact of Gatekeeping on Physician Practice Patterns-A Survey from Cardio Vascular Surgeons

Rapidly increasing health care costs have been a primary motivation behind many proposals to reform the U.S. health care system. In this study, data were provided by a Medicare Heart Bypass Demonstration Project at Methodist Hospital of Indiana. Under the Health Care Financing Administration (HCFA) contract, physicians needed to consult and interact with one another to provide care for coronary artery bypass graft (CABG) surgery patients. Due to the change of the payment mechanism, cardiovascular surgeons, cardiologists, anesthesiologists, and radiologists were paid under a fixed-fee payment system, while other physicians were paid on a fee-for-service basis. In this model, the cardiovascular surgeon directly controlled the medical resources in the network and authorized additional physician services provided for by other sub-specialists. The cardiovascular surgeon then acted in the role of gatekeeper and influences other practice patterns and clinical judgments. This study generated hypotheses concerning the effects of cardiovascular surgeons acting as gatekeepers in providing care over an extended period of time. Time series analyses and structural equation modeling (SEM) were utilized to examine the effectiveness of gatekeeping. This study found that the effectiveness of gatekeeping increased over time. Gatekeeping resulted in a reduction in resource utilization and hospital costs whereas physician charges increased over time. Gatekeeping appeared to have weaker effects on controlling resources and costs for older, female, and sicker patients. Finally, there were minor differences in the way that cardiovascular surgeons performed the gatekeeping function.