The classic gatekeepers for health maintenance organizations slowly are being removed from their posts.

Patient and provider dissatisfaction with the gatekeeper HMO model -- where patients must go through primary care physicians for referrals to specialists -- along with a lack of proof that gatekeeping holds down costs, is opening up patient access to specialized care.

The gatekeeper model is "rapidly disappearing," and there's not much support to keep it, said Barry Rosenfeld, a consultant with Apex Management Group Inc. in Princeton, N.J. "There's no pressure to keep the gatekeeper," he said. "I haven't seen anyone out campaigning for it."

Mr. Rosenfeld and others question whether any savings that come from the gatekeeper system are worth the effort. "I'm not sure anyone ever proved it was truly advantageous as it affected bottom-line costs or quality of care," he said.

"We don't have enough history to know if the cost would be significantly more if you take the gatekeeper away," agreed John Erb, area vp with Gallagher Benefit Services in Boca Raton, Fla.

Barbara D. Levine, vp-national consulting practice at The MEDSTAT Group in Stamford, Conn., said: "The feeling generally is that (removing) it wouldn't necessarily have to add to costs. It would depend on the benefit plan design. If you're passing on the cost through a higher copay, there would not be much impact on employers."

The gatekeeper function is responsible for a small percentage of the overall cost savings afforded by managed care; a loosening of that function probably wouldn't greatly affect costs, she said.

The debate is leaving employers in an uncomfortable position. Some are hearing complaints from employees frustrated with their inability to see specialists without first making trips to their primary care physicians. Employers must balance that concern with their own worry that allowing unfettered access to specialists could drive up health care costs.

"Employers are sitting on the hot seat," said Dr. Thomas D. Barela, a Phoenix-based physician and medical director for The Segal Co. With only so much discretionary income to spend on health care, employers have to be careful not to let costs spiral out of control, he added.

Ms. Levine said employers are divided over what to do with the gatekeeper model. "Some employers aren't ready to let go because they are concerned about increased cost. Some say employees won't stand for it, so they have opened it up completely."

Mr. Rosenfeld pointed out that pressure to remove the gatekeeper

has been building for a long time from patients who don't like having a single physician taking responsibility for all their health care needs.

Mr. Erb said the "single most irritating aspect of managed care, from an employee perspective, is the gatekeeper function."

He said that while the system worked well when managed care first began gaining acceptance, "10 or 20 years later, we're looking at the system and saying, 'Wait a minute; why does a child with a broken arm need a referral to an orthopedist?' "

The inconvenience to employees is one reason that Sbarro Inc. opted for a preferred provider organization without a gatekeeper restriction.

"We've resisted going to a gatekeeper plan; we just don't believe in it," said Ash Kilada, director of risk management and benefits at Comack, N.Y.-based Sbarro.

Mr. Kilada said Sbarro's approach hasn't raised costs significantly. "I've seen the breakout for specialists visits, and it's really minimal. I don't think it's a big portion of our costs," Mr. Kilada said.

He pointed out that Sbarro has other controls in its plan that are as effective "if not better than a gatekeeper," in controlling its health care costs. He said high deductibles and a copayment prevent employees from seeking expensive treatments unless they really need them.

Sbarro's network is made up of general practice doctors and specialists. A consultation with any network provider costs the employee $10. If a procedure is performed, the patient pays a $250-per-year deductible and 10% of the treatment cost above that amount.

Seeing a provider outside Sbarro's PPO bumps up the deductible to $400 a year. The 10% copay requirement after hitting the deductible still applies.

Not all employers, however, are critics of the gatekeeper system.

At Hartmarx Industries Inc. in Chicago, the gatekeeper HMO is "serving its purpose," said Michael Pikelny, corporate actuary and employee benefits consultant. "Most of our employees know, when they sign up for the HMO, that they are restricted as to whom they can see. We haven't had that problem here," he said, regarding employee dissatisfaction with the gatekeeper arrangement.

Mr. Pikelny pointed out that a patient with an emergency can see a specialist immediately, whereas non-emergency care from a specialist may require the patient to wait, perhaps up to three weeks, for an appointment.

Mr. Pikelny said he is sure that without the gatekeeper control

in place, his company's health care costs would rise. "Absolutely. The main reason HMOs have been able to provide service at a lower cost. . .is the gatekeeper factor. If you do away with it, it seems it would have to lead to higher costs."

Physicians aren't the biggest fans of the gatekeeper model, Mr. Rosenfeld said. "On the provider side, I don't think there has ever been tremendous acceptance or fondness of the concept."

Mr. Rosenfeld said anecdotal evidence suggests physicians feel some pressure as gatekeepers to keep the patient at the primary care level. That makes some doctors uncomfortable, he said, because they feel pressured to provide care that they believe specialists should deliver.

HMOs have reacted to the debate by making changes that eliminate or streamline the physician's role as a gatekeeper.

PacifiCare Health Systems Inc., for example, last year began offering to PacifiCare of California members its Express Referrals program. The program lets a primary care physician send a patient -- after an office visit -- directly to a specialist in any of 16 fields, including cardiology, dermatology, neurology, obstetrics and gynecology, and others.

The new program allows doctors and patients to avoid long waits for approval to see specialists, said a spokeswoman for PacifiCare Health Systems. Before the program was introduced, most approval requests were granted anyway, she said, and the Express Referral system eliminates much of the administrative work that was needed to gain the approvals.

The program has been expanded to PacifiCare operations in Texas, and the parent company plans to offer it in other states, the spokeswoman said.

Kaiser Permanente, a large HMO based in Oakland, Calif., never has used gatekeepers.

"We don't use the gatekeeper model," said Dr. Sharon Levine, associate executive director at Kaiser Permanente in California. "It doesn't make any sense, given our group practice."

Kaiser members can make appointments directly with specialists in several practice areas. Someone with a skin problem, for example, could call the plan's dermatology department to schedule an appointment with a dermatologist.

Kaiser is working to speed up access to specialists in other ways, Dr. Levine said. One method is through the HMO's "bone phone," which gives a physician an immediate link to an orthopedist. Dr. Levine explained that a pediatrician treating a child in the physician's office, for example, could reach an orthopedist who carries a cellular phone. The orthopedist could then give advice over the phone or come to the office to take a look at the child.

Ms. Levine of The MEDSTAT Group pointed out that many HMOs have made moves to change the role of the gatekeeper. "There are a number of different ways of approaching it. I think

health plans are getting very flexible in response to employee concerns."

Dr. Barela said there is a new tendency to create illness-specific networks, being formed to exclusively treat, for example, diabetics, patients with renal disease, patients with oncology needs, and others.

"There is data that suggests that, given the choice, patients will choose a specialist as their primary care physician if they have a specific illness," he said.

Even as it appears that the gatekeeper is vanishing from the scene, some controls on patient access likely will remain in place, according to Dr. Barela.

After all, the original concept of managed care "was for the patient to give away choice" in return for lower costs, he pointed out.

"There will need to be some mechanism, whatever it is," Dr. Barela said. "Some form of controls will be needed."

Ms. Levine noted that while employers and plans are responding to patients' concerns about restrictions to access, "that doesn't mean they're all ready for the gatekeeper models to disappear. There isn't good evidence that it saves or costs any substantial money."

Mr. Erb said the evolution of the current system is "definitely a work in progress. It's gone about as far as it can, it seems, with the classic gatekeeper HMO. The question is: Where do we go next?