✪✪✪ Advantages Of Gatekeeping In The Healthcare System
We divided the participants into two groups gatekeeping and Bomb Incident Plan according to their type of insurance. Figure 1 Goth Dbq the distribution of propensity Advantages Of Gatekeeping In The Healthcare System before and after matching between the two groups. Advantages Of Gatekeeping In The Healthcare System lowers the costs Advantages Of Gatekeeping In The Healthcare System health care for those who have access. Here Advantages Of Gatekeeping In The Healthcare System should note how you used your skill set to address any challenges Advantages Of Gatekeeping In The Healthcare System utilize any helpful dynamics. In both groups, most of Advantages Of Gatekeeping In The Healthcare System respondents were migrants, married, employed, not contracted Advantages Of Gatekeeping In The Healthcare System a GP, with an excellent or good health status and without chronic Pony Boy Book Report. Sorry, a shareable link is not currently available Paul Ryans Argumentative Analysis this article. They mainly disseminated the information through brochures and health education lectures.
Is your Doctor a Gatekeeper?
The third role are the influencers. Roles e. Here you should note how you used your skill set to address any challenges or utilize any helpful dynamics. Be specific in the behaviors you observed. University of Phoenix Material Health Insurance Matrix As you learn about health care delivery in the United States, it is important to understand the various models of health insurance to develop a working knowledge as you progress through the course. The following matrix is designed to help you develop that knowledge and assist you in understanding how health care is financed and how health insurance influences patients and providers as important foundational information for your role as a future.
The Pros and Cons of the American and British Health Care Systems By examining both the United States health care system and the British health care system, it will provide insight of which elements of each system are beneficiary and which elements of each system are disadvantages. Therefore, this paper will provide an overview of the pros and cons of each system to decide where improvements need to be made. What kind of payment system is used, such as prospective, retrospective, or concurrent?
Who pays for care? What is the access structure, such as gatekeeper, open-access, and so forth? How does the model affect patients? Include pros and cons. How does the model affect providers? Indemnity In the American Medical Association AMA adopted a strong position against prepaid group practices, favoring instead indemnity-type insurance that protects. GPs provide basic healthcare to their patients, such as checkups, prescribing medication, and overseeing minor health concerns.
As a gatekeeper, GPs refer patients to hospitals or specialists for further services that they cannot provide themselves. Patients cannot see a specialist or receive treatment. A gatekeeper is a primary care provider who acts as an agent for patients. They coordinate medical care so that patient receives appropriate services and also provide referrals to specialists. Typically, primary care physicians include family practitioner, generalist physician and pediatrician. Ideally, gatekeepers are much like family doctors, they focus on the health of the person as a whole instead of a single organ. They help emphasize prevention care and establish appropriate health screening based on the patient. On the hand, there are concerns that the system of gatekeeping makes urgent care inconvenient.
The pros and cons surrounding the system of gatekeeping really question its effectiveness. On the other hand, no system is …show more content… Having a primary care provider not only gives you a personal health care organizer but it also reduces your health care cost. In a pharmacy, one also asks patients about their conditions and then dispenses medicines. Here things are basically the same… For some patient I would suggest blood test, [but we cannot provide that]… I can only give them some drugs that fit with the symptoms.
We have all the examination devices but nobody to operate them. Primary care facilities were in the process of conversion to community health centres, therefore eliminating some main functions related to the mini-hospitals that they used to be. Inpatient care had been virtually eliminated, as had surgical operations. Reduced clinical experience and dysfunctioning equipment of primary care facilities contributed to the decline of primary care capacity. Two township health centre managers complained that:. The regulations unwittingly reinforced a process of breaking down the capacity in curative care and identity of what it meant to be a doctor at primary care level, and constructed a vicious cycle of primary care capacity.
As primary care doctors were seen by both themselves and patients as losing their key competence, the patients who sensed serious illnesses just turned to hospitals without visiting township health centres. The vicious cycle was also reinforced by the unintended consequences of other policies beyond gatekeeping that did not attend to the complexity involved in reforming primary care. Particularly, the nation-wide essential pharmaceutical policy [ 54 ], while reducing purchase prices for patients, restricted the pharmaceuticals that primary care doctors could prescribe. The restriction was made worse by the additional difficulty of transport in the countryside. A patient complained passionately about the restriction of access to pharmaceuticals:.
Exacerbating the vicious cycle described above, the performance evaluation system was driving the primary care facilities further away from providing curative care. M03 and M04, interviewed in A young doctor in a pilot township health centre, who had trained in clinical medicine, spent most of her time in the community health department of the township health centre, and was doing little clinical work because of the intense pressure of performance evaluation, and her youth and hence lack of trust by patients, and low patient volume.
She said:. But since it was the requirement of work, I had no choice. This pivot was also reinforced by the reduced patient visits and contributed to a downstream reduction of the attractiveness of jobs as a primary care doctor. None of the interviewed doctors who were spending their time in disease management were happy about the situation. Recruitment in the facilities mainly targeted medical graduates with a three-year associate degree a full medical degree would require minimally five years of training. Even that was difficult according to a district health administrator M03, interviewed in Related to issues facing human resources was another reinforcing loop that further challenged the intention of the gatekeeping programme to reduce the number of patients bypassing primary care facilities.
As the focus of primary care doctors shifted towards public health services, patients noticed that their service function was reduced. P03 interviewed in When considered together, R1a, R1b and R1c formed a very strong tendency towards further declining functions and capacity in primary care facilities, and erosion of the professional status of doctors. The hospital manager interviewed said:. Those with real problems would be referred to tertiary hospitals… Regarding back referral [from hospitals to township health centres], to be frank, we operate according to the demand of patients… If the patients believe it is inappropriate, we have to give up… There are very few back referrals [in practice].
Besides the challenges within the primary care sector, difficulties for gatekeeping also came from the interface with hospitals. In order to improve the level of skills, there was a training system in which newly recruited medical graduates at primary care level underwent further training at hospitals. According to a hospital doctor and an officer of the district health bureau, many seemed ready to give up their position in primary care if they were offered a position in the hospitals. An interview with the district hospital manager M05, interviewed in revealed that the brain drain of primary care was mainly limited by the already depleted reservoir of capable primary care doctors. In fact, the hospitals were actively recruiting graduates with not only a university medical degree but also masters graduates three extra years of medical training.
The result perhaps was not just reduction in recruitment at primary care level but also a deterioration of quality and a further divergence of professional status and aspiration. As the same manager in the district hospital argued, some who preferred to stay at primary care facilities were happy that way, because of a light workload and a steady income—less stressful compared to hospitals. Related to this was the increasing hospital visits associated with the hospital incentive structure linked with revenue generation.
The hospitals also used such revenue to build up their advantage in equipment and infrastructure. In short, the comprehensive structural advantage of the hospital fed back to its functional advantage in that it attracted ever more patients. The advantage of hospitals also fed back to the policy making process. In other words, the opposition from the interests related to hospitals were challenging the sustainability of the gatekeeping pilot in its current design. Indeed, the municipal NCMS administrator was considering replacing the pilot programme by moving the fundholding role i.
Patients found primary care facilities to be very restrictive in services, technologies, and pharmaceuticals, and felt they received little extra benefit when they came to visit primary care facilities for referral. The extra visits became a burden to primary care facilities, too. Will you say that is not troublesome for them? It is understandable that patients complained… They are not willing to come here to get referral. Most doctors and patients considered the policy an inconvenience, though some also acknowledged that the policy brought additional opportunities to make contact with patients.
In several cases, patients went to hospitals first, and later found that they had to get a referral from primary care doctors when they tried to claim reimbursement. Furthermore, there was little integrative care arrangements e. The referral requirement thus became largely ritualistic, which added to the resentment of doctors and patients. In particular, gatekeeping hurt local elites who had more say in the political process e. One limitation is that the study did not allow interviewees or independent experts to validate the causal loop model, which has been recommended [ 55 ].
After a failed attempt to explain an earlier draft of the CLD to some municipal policy makers, the lead author found it difficult to use the CLD as a communication tool to policy makers who had little prior training, and to explore this further was beyond the capacity of the study. The findings should therefore be seen as the understanding of the researcher, generated through a rigorous process. The approach used in this study seems to have advantages in understanding the complexity involved in shifting balance of care through interventions like gatekeeping. The use of the WHO categorisation of health systems building blocks facilitated a systematic mapping of factors related to gatekeeping. In the study, applying the categorisation facilitated the identification of issues directly related to the mechanisms of gatekeeping such as financing e.
The application of a CLD has allowed the study to bring together the separate analyses to understand the interrelationships between different factors within and across categories of building blocks. One particular advantage is related to dealing with unintended consequences of policies indirectly related to gatekeeping e. The CLD also has allowed the study to identify both local patterns of feedback loops and how these feedback loops formed a holistic picture of all the key factors related to gatekeeping. Overall, the approach bridged analysis of the gatekeeping pilot with analysis of the system within which the gatekeeping pilot was embedded.
The approach brought into the qualitative evaluation of gatekeeping the three dimensions of interrelationships, perspectives and boundaries, highlighted in the systems literature [ 43 ]. It revealed the richness of interrelationships among different factors within the health system that were directly or indirectly related to gatekeeping functioning, reflected the multiple perspectives of different groups of stakeholders, and encouraged a deeper understanding of the boundaries by highlighting the linkages between the intervention and the system, as well as by examining unintended consequences of the gatekeeping pilot. Furthermore, the approach of qualitative systems analysis developed in this study was explicit and transparent.
A systematic review of the recent use of system science and systems thinking for public health suggested that studies using systems modelling methods should make the formulation of models in this case a CLD explicit enough for readers to judge the rigour of the studies or to repeat the process [ 55 ]. The complicated process and lack of transparency of interim stages made causal loop analysis prone to issues regarding accountability.
The danger of misunderstanding the system based on a model with suboptimal rigour is also amplified by the assumed interconnectedness of the factors. However, guidance on how to rigorously develop CLDs based on qualitative methods and data have been lacking. This study has established an example of a transparent and rigorous approach to qualitative systems analysis of a complex health systems intervention. The study has presented the first evidence on the intended and actual functioning of gatekeeping in a pilot in rural China. The intended supply-side incentive on treating a greater number of patients at local facilities did not seem to have functioned as expected, as the salary policy was too rigid with a level of pay too low to either attract or incentivise gatekeeping-related clinical work.
On the demand side, a large number of patients appeared to be going through primary care reluctantly to get referral in a generally ritualistic process. The implementation of the approach of gatekeeping in the studied pilot led to dissatisfaction of both doctors and patients. This contradicts a patient survey done in Shenzhen [ 56 ] that showed stated willingness of local residents to accept community health centres as gatekeepers. Besides public resentment, potential adverse effects included delay of diagnosis or misdiagnosis. The study did not investigate this issue directly, but the weak primary care capacity suggested that this would be hard to avoid [ 34 ], if a significant number of patients relied on the primary care providers.
Furthermore, given the different capacity of primary care facilities and hospitals, implementing gatekeeping only for the NCMS could potentially exacerbate inequity by restricting their access to facilities of lower service quality. The study identified three aspects that led to the sub-optimal functioning of the gatekeeping pilot. First, the weak conditions of primary care, particularly regarding the clinical skills of primary care doctors in comparison with those in hospitals, seemed to be a fundamental barrier facing the reform. The nation-wide gap between qualifications of primary care doctors and hospital doctors was sustained over the recent decade when social health insurance coverage was extended to the whole population [ 57 ].
Therefore, it was understandable that patients in the pilot townships were not satisfied when their eligibility for direct access to ambulatory services in hospitals were taken from them. The lack of progress in reforming hospitals exacerbated the imbalance between the two sectors. Despite reform in primary care, the inflationary incentive structure in hospital care remained unchanged. Hospitals were systematically absorbing human resources, patients, and other resources, contributing to greater imbalance in the system. Hospitals particularly the district hospital in the pilot area have become increasingly the main provider of curative care and received most of the total medical expenditures.
This is corroborated by a quantitative analysis comparing nation-wide service utilization in hospitals and primary care providers in recent years [ 57 ]. The self-reinforcing nature of the imbalance between hospitals and primary care facilities could mean increasing difficulty in future reforms. Third, the effectiveness of gatekeeping was hampered by the unintended consequences related to conflicts among different priorities required of primary care development. Primary care facilities have been loaded with much aspiration for the ultimate goal of universal health coverage in low- and middle-income countries.
There coexisted multiple policy initiatives in the pilot as well as China-wide: strengthening the function of primary care facilities in curative primary care, strengthening the function of primary care facilities in preventive primary care for the increasingly prevalent non-communicable diseases, curbing over-prescription related to the previous incentive structure, and reducing pharmaceutical prices. These intersecting reforms provided plenty of scope for clashes and inconsistences. The findings suggested challenges in changing the functions of primary care facilities, as primary care facilities have relied for years on mechanisms similar to those in the hospital sector revenue-generation, recognition of professional status focused on treating diseases, etc.
The effort to strengthen chronic disease prevention e. However, it might undermine efforts to provide more and better curative care at primary care facilities, and even break down the appreciation of professional status and competence of primary care practitioners by both patients and colleagues. The essential drug policies, which seemed to have unintendedly led to limited access to pharmaceuticals at primary care facilities, also restricted the range of services available at this level. Previous studies have suggested these were common challenges facing primary care facilities in China [ 6 ], though our study further elucidated the underlying dynamics.
However, most of the policies involved with the exception of gatekeeping were made nationally and implemented nation-wide. The issue of structural and functional imbalance between hospitals and primary care facilities has been a nation-wide phenomenon as reflected in the references cited above from nation-wide studies. On the basis of what Yin defined as analytical generalization, which builds generalization upon theoretical comparability [ 58 ], this first qualitative evaluation about a pioneer gatekeeping pilot is relevant to comparable settings in rural China, which faces essentially similar challenges. Overall, the study has suggested that the gatekeeping pilot failed to alter the dynamics involved in an increasingly imbalanced local health system.
If scaled up and strictly adopted in settings with weak primary care, gatekeeping of the kind implemented in the pilot could lead to other undesirable outcomes. These might include public resentment and other unintended consequences in equity and quality of care e. Gatekeeping pilots need to be attempted in areas with better primary care conditions, and combined with supporting policies, including collaboration with hospitals, perhaps selectively for specific health problems. More broadly, the difficulties facing primary care strengthening in rural settings also indicated the risks related to a lack of appreciation of the complexity involved in primary care functioning in reality and the potential and manifested conflicts among multiple reform priorities, as well as lack of progress in hospital reform.
Measures to strengthen primary care should be careful not to change too fast the function of doctors without managing professional aspirations, while they should also be bold enough to promote consistent and harmonised changes. The converging point of primary-care-related policies in rapid and multidimensional transition on multiple fronts should be centred on the people at the core of primary care delivery. What is needed seems to be a systemic effort to reconstruct primary care professionals. Such efforts should not be stand-alone policies such as training general practitioners, but a human-centric reform expanded to cover the clarification of organizational functions of primary care facilities with development of primary care teams, adequate financing of primary care, professional development, and other supporting elements including access to technologies and medicines.
In addition, reform of hospitals to constrain their profit-orientated expansion should also be pushed forward. In this paper, we have presented a qualitative systems analysis of how gatekeeping functioned under constraints in a pilot in rural China. The study has revealed the ineffectiveness of gatekeeping in shifting the balance towards primary care. The current salary policy was too rigid with a level of pay too low to either attract or incentivise gatekeeping-related clinical work.
The study has suggested a number of underlying systems factors that restricted the functioning of gatekeeping in the pilot area. The weakness of primary care capacity particularly in terms of human resources lay at the heart of ineffective gatekeeping. Primary care facilities were also trapped in vicious cycles. Particularly dangerous was the phenomenon that the primary care doctors were losing patient trust and professional aspirations. Unintended consequences of a number of concurrent policies also impeded strengthening of primary care functioning. Strict regulation on pharmaceuticals and the technological imbalance between primary care and hospitals limited the medicines and technologies available to primary care facilities.
The delayed reform of perverse hospital incentives also contributed to the barriers to successful functioning of gatekeeping. The findings imply that two kinds of logic are needed in formulating policies to improve the underlying conditions of gatekeeping. On the one hand, the vicious cycles that primary care facilities were facing requires bold and timely measures. In particular, it seems necessary and urgent to elevate the competence of primary care doctors, who should also be provided with career prospects. Hospital reform should also be pushed forward to tame their profit orientation.
On the other hand, the findings suggest caution on reforms regarding primary care. Rather than shuffling of functions, the policy makers should design reform in which primary care doctors can consolidate their professional standing and the trust of patients and colleagues. There should also be mechanisms to learn from experience and make timely policy adjustments.
The study has demonstrated the use of a qualitative systems approach to study a complex health system intervention, and identified the limitations and value of the approach. Further research may build on the transparency demonstrated in this study and the approach to model construction should be recorded and reported clearly. Future studies with more resources might offer a training course to policy makers on the value and use of CLDs. United Nations. New York: United Nations; Google Scholar. World Health Organization.
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Geneva: Switzerland; Ritchie J, Spencer L.Forrest Advantages Of Gatekeeping In The Healthcare System, Starfield B. Muir Mans Place In The Universe Analysis E. The advantage of the NZ healthcare system which uses gatekeeping is that it provides access to a larger range of people. The Advantages Of Gatekeeping In The Healthcare System the score complexity, the more the barrier to calculation, as it Advantages Of Gatekeeping In The Healthcare System the probability that some Advantages Of Gatekeeping In The Healthcare System inputs may not be available. The Institutional Review Advantages Of Gatekeeping In The Healthcare System of Sun Yat-sen University reviewed and approved this method of obtaining verbal consent Advantages Of Gatekeeping In The Healthcare System patients. Most long-term care insurance policies require long-term Summary Of Florence Kelley Child Labor to be medically necessary for sickness or injury. There are many industries where gatekeepers are necessary.