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“Targeted Gatekeeper Model” for Specialist Referrals Gains Momentum Under Accountable Care and Value-Based Reimbursement

In the 1980s and 1990s, health plans and other payers depended on primary care physicians (“PCPs”) to be the gatekeeper for referrals to specialists. Covered members were required to select a gatekeeper in order to receive medical coverage. This gatekeeper model was not successful for several reasons. “Research studies showed that gatekeeper models generally were no more efficient at curtailing medical trend than non-gatekeeper plan designs. Also, large employers wanted more open access to specialist care for their employees,” stated Dr. Douglas G. Cave, President of Cave Consulting Group (“CCGroup”).

He continued, “As medical trend continues to drive medical care costs ever higher, health plans and employers are thinking of re-implementing the gatekeeper model – but in a more structured, targeted manner. One reason is that overall episode of care costs are significantly higher when both a PCP and specialist are involved in treating prevalent medical conditions.” For routine heartburn (known as gastroesophageal reflux disease (GERD)), the average episode cost is $400 when only a PCP is involved in treatment, but dramatically increases to $1,500 with specialist involvement. Also, for routine low back pain, the average episode cost is $600 with only PCP involvement, but significantly increases to $2,000 with specialist involvement.

Research performed by CCGroup shows that PCPs are involved in treating only 40% of prevalent, medical condition episodes of care with the most practice variations. These episodes include routine low back pain, GERD, headaches, degenerative joint disease, and ischemic heart disease. Of this 40% of episodes PCPs are involved with, PCPs presently refer about 35% of these episodes to specialists.

Under accountable care, PCPs need to become more active participants in treating medical conditions with significant practice variations. “We need a Targeted Gatekeeper Model that allows PCPs to become more active participants – while at the same time enables employees to have fairly open access to specialists,” affirmed Dr. Cave.

“CCGroup is the first company to develop the Targeted Gatekeeper Model – and our clients are seriously contemplating the significant merits of this approach. The initial step is to identify those 10 medical conditions and services (MedMarkers™) with the most practice pattern variability. These identified medical conditions (which are different for every client), drive over 50% of all cost and quality improvements,” stated Dr. Cave.

He defined, “These are the few medical conditions where the Targeted Gatekeeper Model should be applied and implemented into provider value-based reimbursement arrangements. These conditions are where PCPs should become more active participants in care. These few medical conditions are where clinical leaders should develop quantitative clinical pathways that define the appropriate time for a specialist referral. And when a referral is appropriate, PCPs need to refer to efficiently and effectively practicing specialists.”

Each of the steps in the Targeted Gatekeeper Model needs to be done accurately and reliably, if the model is to be successful. Each of the steps needs to be monitored over time to ensure success. Successful implementation will result in the avoidance of millions of dollars in unnecessary healthcare expenditures, while patient quality and continuity of care increases.

About Cave Consulting Group, Inc. (CCGroup)

Cave Consulting Group, Inc. is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 27 years for health plans, HMOs, physician groups, health systems, TPAs, and employers.

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