Colorado State University Role of Primary Care Physician as Gatekeeper Questions

I’m studying and need help with a Nursing question to help me learn.

Prompt – DUE SATURDAY 10/17- APA format-

Assume you are working for a large managed care company and you have been tasked with the role of reducing costs on unnecessary services. Explore the website Choosing Wisely (Links to an external site.). Identify a medical procedure or service that is either not cost efficient or should potentially not be offered at all. Prepare an Executive Summary to present to your supervisor that answers the following questions:

• A description of the identified service.
• Should it be reserved for only specific populations or completely eliminated?
• Explore potential reasons why this specific procedure or service is still being offered despite it being inefficient or unnecessary.
• Why should the specific changes you recommended be made?

The Executive Summary should be well-written and meet the following requirements:

• 2 pages in length,
• Formatted according to the CSU Global Writing Center (Links to an external site.), and
• Include at least three references from peer-reviewed articles beyond the text or other course materials. The CSU Global Library is a good place to find peer-reviewed articles.
• Be sure to discuss and reference concepts taken from the assigned textbook reading and relevant research.

Reading–

1. Role of the Primary Care Physician as Gatekeeper

In managed care systems, the primary care physician (PCP) serves as the “medical home” for the patient and as the gatekeeper for the managed care organization (MCO). The term gatekeeper is used because many health plans do not allow patients to self-refer. Instead, the PCP must make the referrals to other professionals for consultation and specialty treatment in order to ensure appropriate utilization of non-emergent secondary and tertiary care services.

The practice of medicine is built on the sanctity of the relationship between the patient and physician. Physicians have an ethical duty and professional commitment to act in the patient’s best interests. When a PCP detects or suspects a certain illness or disease, the patient may be referred to one or more specialists, such as a cardiologist, oncologist, or a surgeon. In other instances, however, the PCP will treat the patient.

For example, if a patient came in with a slight fever and requested a referral to an infectious diseases specialist, the PCP would most likely deny this request and would instead treat the patient himself. Conversely, a patient reporting regular and unresolved problems with heartburn would most likely be referred to a specialist (such as a gastroenterologist) for testing and treatment. In the first example, unnecessary care is not provided, and in the second, the patient is referred for care that is indicated. In each of these examples, the physician maintains professional integrity and ensures that proper care is provided.

When thinking about the gatekeeper role and how it fits in the overall managed care goals of reducing costs, keep in mind this video on healthcare costs.

2. What Does a Case Manager Do?

Case management is the comprehensive process of assessing, evaluating, planning, coordinating, and facilitating the range of services needed to address a patient’s health needs. The overarching goal of case management is to assist an individual in achieving the optimum level of wellness and functional capability in the most efficient and cost-effective manner possible. This does not mean that the patient will be completely cured or returned to some previous, but now unattainable, level of functioning (Shi & Singh, 2019).

Case managers (other commonly-used titles are care coordinator or discharge planner) are the individuals who help patients reach appropriate and reasonable goals through advocacy, education, and identification of resources, as well as through the coordination of the provision of available services. The work is challenging and demanding. To be successful, they must understand how to work with both the individual patients and their families. They must also possess the critical thinking skills needed to navigate through complex healthcare and social service systems. Click the tabs to view examples of possible responsibilities and settings required of case managers.

In general, case managers have a clinical background. Most are either registered nurses or social workers. Many attain the necessary skills through on-the-job training, while others may complete formal coursework.

3. Evidence-Based Medicine

It is the practice of physicians, through ordering tests and treatments, that largely determines the financial success of healthcare providers in a managed care environment. There are various methods used to influence the physician decision-making process and behaviors to reduce the cost of care. Click on the tabs to explore some of these methods.

The concept of evidence-based medicine (sometimes called evidence-based practice) generally refers to the appropriate use of current evidence from published medical research when making decisions about patient care. EBM is not intended to completely replace physician judgment, but rather to help supplement their knowledge and guide their decisions (CMSA, n.d.).

4. Disease Management

Disease management is often used to refer to comprehensive programs or systems used to coordinate multi-disciplinary healthcare services for defined populations with specific conditions (such as congestive heart failure, diabetes, and stroke) across the continuum of care. The programs generally select chronic conditions that account for a large portion of healthcare spending. The goals of such programs are to improve the quality of care, quality of life, and to reduce costs (Shi & Singh, 2019).

Disease management programs use tactics to improve physician use of, and patient compliance with, evidence-based medicine guidelines and treatment plans. To be successful, the patient must be a full partner in the program, working closely with the care team. Indeed, a primary tenet on which such programs are built is the idea that patients who are educated about their disease are more motivated to properly manage their health (Shi & Singh, 2019).

The most effective programs generally involve numerous healthcare and social service organizations. Thus, coordination and collaboration are essential, but also challenging because organizations may be in direct competition with each other. Thus, many programs are often managed by health plans, insurance companies, or commercial vendors. Further, to ensure collaboration across the continuum, providers are often provided incentives to participate and rewarded when measurable program objectives are achieved. Similarly, plans may use disincentives, such as reduced reimbursement, if providers do not participate or if performance targets are not achieved (Shi & Singh, 2019).

Remember, everything that is being covered in this module is related to managed care and its efforts to control healthcare spending. While learning about gatekeepers, case managers, and disease management, remember that the intention is to reduce healthcare spending. Please watch this video from a renowned healthcare economist, Dr. Reinhardt, to put some of the need for this into perspective.