Behold, the Gatekeeper Cometh

The insidious intrusions of arbitrary restrictive patterns of health care delivev that limit direct access of patients to specialist care were once largely confined in this country to voluntary health maintenance organization‐independent practice association (HMO‐IPA) systems and the military service. In 1981, 87% of surveyed HMOs and IPAs restricted patient access to specialist care to some extent. Such limitation is now becoming more widespread through the creation of primary‐care networks, case management, and experimental programs under Medicaid. Limitation of direct access to specialists will impact substantially on the practice patterns and quality of dermatologic care, because primary care physicians and physician extenders who will control the referral system often will attempt to treat skin conditions even though they frequently misdiagnose the condition. Further, as is often the case, referrals to specialists often will be limited to one visit only, with no opportunity for the specialist to establish a satisfying doctor‐patient relationship or to evaluate the effectiveness of treatment. The following is an analysis of this phenomenon and an assessment of what has been accomplished or remains to be done to combat this trend.