Self-referral in a gatekeeping system: patients’ reasons for skipping the general-practitioner

Abstract

In the Netherlands general practitioners act as the gatekeepers at the primary level to the more specialized and more expensive secondary health-care. As a rule, patients are required to have a referral from their general practitioners to be able to utilize these services. Not all private insurance companies, however, require a referral letter from their customers before reimbursing them for their costs or do not always exert a control whether such referral indeed had taken place. A mail-questionnaire was targeted to a specific group of 2000 privately insured patients to find out the reasons of self-referral. The findings suggest that patients self-refer to a specialist for medical complaints for which they expect to end up at the specialist anyway as they consider these problems as specific for the specialist. Complaints of patients who first visit their general practitioners, however, might be considered as less typical to the specialist. Patients who are living in relatively highly urbanized areas, who are better educated, and who expect to achieve a better quality of communication at the consultation with the specialist, more commonly skip their GPs before visiting a specialist.

Introduction

Currently, two main types of health care systems can be observed in most European countries. On the one hand, there are systems which give patients unrestricted access to the services of medical specialists (e.g. Belgium, France, Germany, Finland, Sweden). On the other hand there are health care systems which refer patients to medical specialists (e.g. England, Denmark, Norway, Spain). The health care system of the Netherlands falls into this second category. In referral systems, general practitioners (GPs) act as the gatekeepers to specialist care. In other words, patient access to more specialized (and more expensive) services of medical specialists is regulated by their GPs. A system in which GPs act as gatekeepers to specialist care generally results in lower health costs 1, 2. An important goal of referral systems is to improve the efficiency and quality of medical care, both at the primary and secondary levels. This explains the interest in gatekeeping both in Eastern European countries that are reforming their health care systems [3] and in the United States where managed care (including a limited access to specialized services) is rapidly becoming the dominant model for insurance and provision of health care [4].

In the Netherlands, however, the application of the general principle of gatekeeping differs in practice, according to the type of health insurance. For the publicly insured-about 60% of the population [5] with an income below a certain annual level-this requirement is absolute. A publicly insured patient in all cases needs a ‘referral card’ written by his¹ GP to be able to visit a medical specialist. Even in cases where a patient directly consults a specialist, for example in emergency cases, a referral card from the GP still has be obtained afterwards. Only with this card, can medical specialists claim their fees to the health insurance fund. The privately insured, however, have more ‘opportunities’ for self-referral before visiting a medical specialist, i.e. at their own volition and not by referral from the GP. For this group of patients, the referral-requirement is dependent on the insurance company they choose. Medical specialists send a bill to their privately insured patients who in turn, are reimbursed by their insurance companies. In spite of the fact that the policy of the Dutch government is to strengthen GPs gatekeeping position, not all private insurance companies require a referral letter from their policy holders before reimbursing them for the bills of medical specialists. In cases where such a referral is required, private insurance companies conduct few checks on whether such a referral had in fact taken place. There are several reasons for this such as the competition between the insurers and perception of the insurers that people do not often skip their GPs before visiting a medical specialist. In a study, however, where heads of out-patient departments were interviewed, proportions of privately insured self-referring patients to out-patient departments were estimated to be between 10 and 50% of the cases [6].

Research on self-referral in countries where the GPs are gatekeepers to the secondary health services is a neglected area. In Denmark, among a small proportion of the population (3%) who chose part self-payment of medical costs and could in turn visit a specialist without referral, the proportion who contacted specialists within a year was found to be higher than among the rest of the population who fell under the compulsory referral rule, but were entitled to receive the services of the GP free of charge [7]. The former group of patients belonged to higher income groups and more often belonged to higher ranks on the occupational ladder. A study in the United States where direct access to certain specialists is increasingly being limited through managed care showed that self-referring parents to paediatricians did so because they thought that the child’s regular physician was unconcerned about the medical problem [8]. A majority of self-referring American patients to internists, on the other hand, did not have a family physician [9].

In systems with restricted access to specialist care, Emergency and Accident (E&A) departments are sometimes used as a ‘safe haven’ for specialist care. In England, a limited number of studies on self-referral focus on this aspect of self-referral. These studies and a few in the United States conclude that patients sometimes use E&A departments as outpatient clinics for convenience, and sometimes also for previously existing medical complaints 10, 11, 12, 13, 14. Further, dissatisfaction with the primary care providers [15] and workload of these providers [14] are given as a reason by self-referrers to E&A departments.

In the Netherlands, studies on self-referral and its relation to the gatekeepers position of the GPs are also scarce. There is evidence that between one-fifth and one-fourth of the contacts between privately insured Dutch patients and medical specialists were ‘initiated’ by the patients themselves 5, 16. However, what ‘own initiative’ means is controversial. A patient who visits his GP with a request to be referred to a specialist also falls into this category, as well as the one who decides to consult a specialist directly. Other studies analysing the gatekeepers position of the Dutch GPs concentrate on E&A department visitors 17, 18. These studies conclude that an important proportion of these patients had medical complaints which could actually have been treated by their GPs.

The aim of this article is to investigate the question of self-referral and to develop a theoretical framework for the phenomenon of self-referral in countries with a gatekeeping system. It is important to understand why patients choose to skip their GPs in these systems. However, we do not aspire to give a representative description of the extent to which self-referral occurs in the Netherlands. Instead, we intend to test some of the hypotheses derived from our theoretical framework. We test the gatekeeping position of the GPs using data from a relatively small and selective group of privately insured patients, namely those who have a financial incentive for skipping their GP. The study can be regarded as a pilot with the aim to shed light on characteristics of self-referring patients and their reasons for not complying with referral rules. In this article there are two main research questions to be explored:

• How is the gatekeeping position of the GPs conceived among the group of patients who has the most interest in skipping the GP?

• To which extent do financial considerations play a role in skipping the GP?

In addition, we have formulated the following sub-questions:

• To which medical specialists do patients mostly self-refer?

• For which medical complaints do patients mostly self-refer?

• What are the socio-economic characteristics of patients who choose to skip their GPs?