What Is a Gatekeeper?

A gatekeeper refers to requirements that must be met before an individual can qualify for a long-term care plan or to an individual who oversees a patient treatment through a health maintenance organization (HMO).

Key Takeaways

  • A gatekeeper can be the requirements needed for an individual to qualify for a long-term care plan.
  • It can also refer to someone that oversees patient treatment as part of an HMO.
  • A medical gatekeeper can help keep costs down, but they can also lead to limited choices for consumers.

How a Gatekeeper Works

A gatekeeper can refer either to an individual person or to the requirements that must be met before an individual can receive any payouts from their long-term care insurance plan. These required standards are referred to as gatekeepers because they are the gate between the individual and the policy payouts. In order to receive the plan’s benefits, an individual must first qualify based on the policy’s requirements.

But a gatekeeper can also refer to a person. In this case, a gatekeeper in the field of health insurance describes the person in charge of a patient's treatment. Anyone who receives health insurance coverage through a health maintenance organization (HMO) plan, has a gatekeeper assigned to them or are allowed to choose one.

Special Considerations

In some cases, the insured party is instructed to choose a primary care physician from a list, and that doctor becomes the gatekeeper for the patient. In traditional HMO situations, the primary care physician is automatically the gatekeeper for a patient’s entire medical care, from approving tests and treatments to issuing referrals for specialty care within the plan’s network. Gatekeepers are also a common characteristic in managed public healthcare systems, such as in the UK and in Scandinavian countries.

The gatekeeper’s job, theoretically, might be thought of as a way to help the patient manage their care within the system, since a patient may not be aware of all the intricacies, rules and regulations in place, so using a gatekeeper can help streamline the process. Gatekeeping, however, does have its criticisms as well. 

Advantages and Disadvantages of a Gatekeeper

Some of the purported pros of using a medical gatekeeper include keeping healthcare costs down by avoiding unnecessary tests and interventions by having one medical professional be the go-to for care and any secondary care.

Some of the cons of utilizing a medical gatekeeper, on the other hand, have been reported as doctors feeling like they are acting more as administrators than providers giving treatment, as well as concerns over primary care providers denying or limiting referrals in order to keep their patient load low, thus, patients feel like they are limited in their healthcare choices.