Solving healthcare's biggest challenge may be only slightly less difficult than untying a Gordian knot. On a daily basis, physicians must navigate the fine line between two conflicting incentives: providing patients with the latest life-saving treatments and trying to keep a lid on costs that threaten to spiral out of control. Their frustration is palpable.
But even the legendary Gordian knot was not invincible. Alexander the Great, on a mission to conquer Persia, cut the knot with his mighty sword and earned himself a reputation as a crafty fellow as well as a fierce military leader. If only reforming healthcare were as easy as conquering the world (at least the known world).
One of the snarkiest healthcare debates revolves around the use of gatekeepers, those much maligned primary-care physicians who control the managed-care plan enrollee's entry point to treatment and access to specialists and other high-cost care.
Increasingly, the question being asked is: Has the gatekeeper concept outlived its usefulness? And more and more, the answer is a qualified yes.
Not that health plans -- or physicians, for that matter -- should give up efforts to manage care. They simply have to figure out, as Norwalk, Conn.-based managed care company Oxford Health Plans tried to do, a better formula for providing freer access to medical specialists at the same time they contain costs.
Even though Oxford has found itself in financial hot water, its experience drove home an important lesson: The public hates the bottlenecks and denials inherent in the gatekeeper system and will flock to health plans that promise to smash them. If a health plan wants to succeed, it needs to replace its gatekeeper with a more acceptable way to coordinate efficient care.
One promising experiment has been the creation of call centers to provide care direction. Foundation Health Systems of Los Angeles is running a successful pilot in Philadelphia that is staffed by nurses. The center has garnered rising customer-satisfaction scores for offering informed medical advice that saves time and money for consumers and providers alike (see September, 1997, page 23).
Another proposed solution is the creation of referral protocols for high-traffic diseases, including automatic referrals to specific specialists, such as OB-GYNs and cardiologists, or limited authorizations for procedures most subject to abuse.
Direct contracting between employers and providers is another promising
It's time to step up the effort to find other workable alternatives to gatekeepers. Like Alexander, those who find a better route may become trailblazers.