The internist as gatekeeper. Preparing the general internist for a new role.

To reduce health care costs, some third-party payers have enlisted primary care physicians as gatekeepers to medical care. In gatekeeper systems, primary care physicians must approve all care provided to their patients. This approval is a condition of payment for the service, with the usual exception of true emergencies. The gatekeeper approach, sometimes called the case-manager plan, extends the responsibility of primary care physicians from coordination to control of medical care. However, for the plan to stimulate cost-effective medical care, it must overcome obstacles that threaten its ability to save money and provide high-quality medical care. If internists are to serve as gatekeepers, then medical educators must ensure that the necessary attitudes, skills, and knowledge are taught to students of internal medicine.