What Are Primary Care And The Related Concept Of Gatekeeping?

"In the past two decades or so, health care has been commercialized as never before, and professionalism in medicine seems to be giving way to entrepreneurialism," commented Arnold S. Relman, professor of medicine and social medicine at Harvard Medical School (Wekesser 66). This statement may have a great deal of bearing on reality. The tangled knot of insurers, physicians, drug companies, and hospitals that we call our health system are not as unselfish and focused on the patients' needs as people would like to think. Pharmaceutical companies are particularly ruthless, many of them spending millions of dollars per year to convince doctors to prescribe their drugs and to convince consumers that their specific brand of drug is needed in

The payment system in the healthcare industry has appealed to specialty care providers, they make a higher income than the primary care physician. The physicians are attracted to specialty care, and the individual feels that specialty care is better. If physicians were all paid well, in order to pay for their education and then continued quality training, we would not be confronting the lack of primary care doctors who are available to treat the general needs of the population (Fisher, 2013). Just as the physicians seem to be treated differently in our health system so are the patients. Using a multi-tiered system of health care where some insurance gives out a higher payment to physicians, some patients seem to be wanted while others are less well received, this leads to an “everyone for himself or herself ethic” within our medical system (JAMA, September).” The design of the system is flawed in reference to the primary care physician and with the patient who has insurance which pays less, the way to reorient both is to make the pay scale more competitive for both. The primary care physician should be able to make money and cover this educational expenses and the patient should have insurance that will equate to

There is a growing trend where physicians are choosing different specialties instead of choosing primary care, primarily due to the low reimbursement rate in primary care. According to Iglehart (2014),” the Association of American Medical Colleges (AAMC) still projects a shortage of 130,000 physicians by 2025, split almost equally between primary and specialty care” (para. 1). With this decline comes an answer, an increase in the number of nurse practitioners providing patient care, reported 154,00 in 2012 and growing every year (Iglehart, 2014). This increase in nurse practitioners’ helps fill that gap, allow greater health care access to the community, especially special populations. By gaining access to healthcare were a nurse practitioner is the provider not only with the special population have high quality affordable health care, a trusting long lasting relationship will develop. This relationship will break the barriers of; lack of trust, lack of health care education and discrimination. Nursing is a trusted profession that provides education and care that no other health care professional

As the health care delivery system developed in the US, right from its inception primary care physicians

Health Care in the United States is a vast industry that has many different types of people involved in the delivery of care. There are stakeholders that affect the daily operations of health care and they are not necessarily in a hospital setting. The Agency for Healthcare Research and Quality, AHRQ, defines a “stakeholder” as persons or groups who have a vested interest in the clinical decision and the evidence that supports that decision ("Effective health care," 2011, p. 1). These stakeholders are making decisions that impact costs, procedures, and the future of

Since the inception of the Nurse Practitioner (NP) role in the 1960s, NPs have thrived in the delivery of primary healthcare and nurse case management. Despite patient satisfaction with NPs ' style of care, nurses have been critical of NPs, while physicians have been threatened by NP encroachment on MD practice. Balancing assessment, diagnosis, and treatment with caring defines NPs ' success as primary care providers. Understand the role and Scope of Practice of NPs is sometimes difficult for some to understand. The purpose of this paper is to define the role and history of NP, compare and contrast licensure versus certifications, understand NP Scope Of Practice and Standards of Care, discuss how the State Practice Acts regulate FNP practice, discuss credentialing and privileging, and differentiate between legislative and regulatory processes.

Critics believe that the present functioning of managed-care is degenerative to health care. Managed-care firms control costs by requiring patients to use a “network” of approved doctors and hospitals, and by reviewing the actions of doctors. Patients have to pay more to visit a doctor who does not participate in the “network.” Managed-care firms second-guess doctors, considering only the costs. Patients are often prevented from visiting specialists to reduce costs. A managed-care company might insist that its doctors prescribe inexpensive generic drugs instead of commercial products. Many patients must, also, receive the insurer’s approval before undergoing treatments or operations. HMOs have been criticized for refusing to pay when a patient goes

Considering the provisions of the Stark law, it is clear that Congress enacted the law to curb the self-referrals that were prevalent among medical practitioners due to the sprawling specialty hospitals and health facilities (Choudhry, Choudhry, and Brennan 2005). Furthermore, Congress saw the need to prevent a physician’s referral decision that is dependent on a selfish, financial gain. The idea was to preclude “overutilization” of certain health care facilities that may arise from objectionable referrals and the resultant increase in health care cost (Staman 2010).

Every individual in the world deserves to enjoy health and wellness. Maintaining or achieving proper health needs enables individuals to be productive at work and leisure. Traditionally, many people have had barriers obtaining adequate healthcare due to economic constraints or personal inconveniences. Despite impressive technological advances in medicine, the challenge of delivering quality healthcare to the Americans continues to be debated amongst the nation’s political and healthcare leaders. The aging baby-boomers and the increased number of uninsured people add to the equation of population growth which results in limited access to primary healthcare for the entire public. On the

As resistant as some states’ legislative and regulatory bodies are to grant APNs autonomy of practice, the damage being done by over-regulation is clear (Safriet, 1992). Physicians are forced into a position to either supervise the APN’s practice or be constantly consulted for approval of their practice decisions. Safriet (1992) described that in and of itself, this constant supervision may appear to patients that the APN is not competent to provide adequate or care equivalent to that of a physician. If the role of the APN is to bridge gaps in health care by relieving the medical establishment of some of the patient load by performing the same function as a physician in a primary care setting, it seems wholly unnecessary to restrain their scope of practice in those areas. This type of restrictions affect cost and patient care accessibility (Safriet, 1992). This was a problem stated in the article, however 25 years later, populations of patients remain unseen or cared for and APNs continue to be underutilized (Safriet, 1992). Rigolosi and Salmond (2014) cite the American Association of Nurse Practitioners (AANP) when they state that not utilizing nurse practitioners due to practice restrictions costs $9 billion annually in the US (p. 649).

Health maintenance organization’s (HMOs) use of the primary care physician (PCP) as the “gatekeeper” initially had MCOs view restrictions as a negative approach to patients’ choices. However, some necessary steps have started to be implemented which reduce unnecessary utilization by enforcing some restrictions.

However, as time went on, several problems arose which had to do with the principle of justice in healthcare. In America, it is the accepted norm that it is unjust to treat one person better or worse than another person, in similar circumstances (Tong, 2007, p.29). In an attempt

Another group often blocked is complementary or alternative health care practitioners. These restrictions and the insurance industry unwillingness to pay for these services, gives the physicians an almost monopolist control over health care. Providers must be able to enter the market for competition to work and there must be many providers vying for the patient. To get the most out of health insurance plans Consolidation of hospitals and multispecialty group practices increases the negotiating leverage of the group but in certain areas of the US a single large medical system has become the sole provider of major health service thereby restricting competition (Shi & Singh, 2008). This consolidation while giving the hospitals and group practice leverage when negotiating prices of supplies and services tends to increase the price of health care to the patient because there is no longer any competition (Shi & Singh, 2008). For these reason “competition will remain less effective in most health care markets, because the prerequisite for fully competitive markets are not fully met” (Federal Trade, 2004, p. 20).

Gatekeeping is a core concept in a primary health care (Grumbach et al.,1998). One of the several key aspects of gatekeeping is to guard patients that have direct access to specialised care (Bodenheimer & Grumbach,2009). General practitioners and other primary care professionals are signified to be gatekeepers (World Health Organisation,2000). Starfield.B (1992), Grumbach & Fry (1993) and Bodenheimer & Grumbach (2009) points out responsibilities of primary care professions (gatekeeper) first, they are to encounter the patient’s health care (Starfield B.,1992) and proceed ambulatory care (Grumbach and Fry,1993). A gatekeeper is the decision maker for opening the gates to a further specialised field after proceeding fundamental primary care on a patient hence, patients are not entitled to direct their own specialists. Also, their purposes are not just to take care of the patient’s wellbeing but giving extensive treatment if any is required (World Health Organisation, 2000) such as, minor illness which includes skin disorders, respiratory infection, headache and common flu, also includes preventive care; vaccinations, immunization and prenatal care are some of the common examples (Heinemann,1980).

Gatekeeping can be defined as, the ability of a primary health care professional to authorize or restrict the access of a patient to specialists, hospitals and other such medical facilities that require primary care physician (PCP) referral (Bodenheimer and Grumbach, 2009). Thus, a patient can only gain access to secondary or tertiary care if they have initially been referred by their PCP. The purpose of gatekeeping in a health care system is to control the number of laboratory tests, therapist as well as specialist referrals (Malcolm, 2004). Gatekeeping occurs predominantly in the primary care sector of the health care system and, the gatekeepers generally tend to be the primary care physicians or qualified nurse practitioners (Cummings,