By NextBestFitEvery person registered with a primary care home
Each resident registers with a primary care practice responsible for coordination.
Every resident registered with a primary care practice, with self-referral for some specialties.
To review: Gatekeeping limits direct specialist access.
Review ledgerHow this path connects
This path
Every person registered with a primary care home
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Register every resident with a primary care practice
- Require referrals for most specialist care
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Medical errors and poor care coordination
Registering each resident with a coordinating primary care practice reduces duplicate tests and lets a clinician see the whole picture.
What it creates or worsens
- Limits choice or applies one rule to every setting
Primary care coordination through registration introduces gatekeeping that limits direct specialist access.
- Physician shortage, especially in primary care
Registering every resident with primary care requires enough primary care clinicians.
5 paths soften this
Fund more residency slotsPhysician shortage, especially in primary careChosenRaise primary care pay relative to specialtiesPhysician shortage, especially in primary careChosenEasier licensing for foreign-trained physiciansPhysician shortage, especially in primary careChosenShorter training: combined undergrad/medical programsMedical education debt shapes specialty choiceRejectedFull practice authority for NPs, PAs, pharmacists, dental therapistsScope-of-practice limits waste capacityChosen
Who's affected
Who gains
- People with ongoing or specialist care needs
- Medical errors and poor care coordination: Delivery and coordination failures cause preventable harm.
- Specialist clinicians and practices
- Physician shortage, especially in primary care: Scarcity supports incumbent specialists’ pay.
Who loses
- Hospitals, clinics, and care organizations
- Medical errors and poor care coordination: Fee-for-service providers are paid for treating complications.
- Residents of areas with too few health professionals
- Physician shortage, especially in primary care: Physician shortages leave them waiting for appointments.
- Doctors, nurses, and other clinicians
- Physician shortage, especially in primary care: Physician shortages contribute to burnout.
Other ways to soften the losses
- Allow self-referral for some specialties
Where it has been tried
- Denmark, Netherlands, UK: GP registration and referral gatekeeping.
- Netherlands: A 2020 Commonwealth Fund profile reported that over 95% of Dutch citizens were registered with a chosen GP, who serves as a referral gatekeeper.Sources: Commonwealth Fund (2020)