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Keywords Doctors, Health care, Decision making
Abstract Assesses the degree of self-reported implementation of gatekeeping in clinical practice, and gains insight into primary care physicians' attitudes toward gatekeeping and their perceptions of necessary conditions for implementation of gatekeeping in daily practice. A self-- administered questionnaire was mailed to a national sample of 800 primary care physicians in Israel, with a response rate of 86 per cent. Multivariate analysis indicated that sick fund affiliation was the main predictor of self-reported implementation of gatekeeping, while specialty training predicted primary care physicians' attitude toward this role. Close communication with specialists, continuous medical education, and management support of physician decisions were identified by respondents as being important conditions for gatekeeping. Discusses strategies to gain the cooperation of primary care physicians, which is necessary for implementing an effective gatekeeping system.
Western countries with strong primary care systems manage to provide high quality health care while containing health care costs (Grumbach and Fry, 1993; Starfield, 1992; Wachter, 1995; Grevas et al., 1994). To this end, primary care physicians are encouraged to assume the role of "gatekeeper", which has three distinct elements: managing and coordinating the patient's care, acting as the sole referring agent to specialists, and applying financial considerations in medical care (Franks and Clancy, 1992; Starfield et at, 1994; Martin et al., 1989). Ideally, gatekeeping should enable primary care physicians to meet patients' needs while making optimal use of health care services. The primary care physician who acts as a gatekeeper advises on health care, protects patients from over-testing and over-treatment, coordinates and ensures continuity of care, and critically evaluates the appropriate use of medical services and everincreasing new technologies.
In Israel, since enactment of the National Health Insurance Law in 1995, all of the sick funds have been operating within restricted budgets, carrying deficits, and coping with financial problems (Gross et al., 1999). To contain costs, they have considered adopting a policy recommended to the Minister of Health by the National Council of Primary Health Care in 1998, whereby primary care physicians will act as gatekeepers. On one hand, the gatekeeper is the patient's "health adviser". On the other hand, he can make judicious decisions about the best and most appropriate use of medical services, and thereby...