Case scenario:
Being accustomed to military life, managed care is all I know. I joined the military at 17, so all of my adult life I've been treated in a managed care system. I was an EMT in the Air Force, worked on wards and clinics, but trained in a managed environment. Having a referral to go see another physician, or specialist was mandatory. You could not make an appointment without a referral in the system from your Primary Care Physician. Not to mention, the referral had to be no more than 30 days old; in my opinion that was not always a bad thing. This was their way of ensuring that your primary doctor was aware of your condition, whether acute or chronic, and suggested or referred you to another doctor that could better manage your care. With PPOs, whether gatekeeper or non-gatekeeper, employees and their eligible dependents typically only pay a small co-payment when they visit preferred providers (Wright, n.d.).
However, that could also be an issue if the patient wanted to be seen in a specialty clinic, or otherwise, for a problem they believed they needed additional advice or care for, but the PCP doesn’t agree. Without that referral the patient doesn’t get very far. The patient could always request a change of their PCP, but that may take another 30 days, thus stalling the treatment they may or may not need. If the facility did not have that specialty available, the patient may have the option of going somewhere else, but still within the network. Going outside of the network only puts the patient at risk of incurring all costs out-of-pocket. Often, participants must pay any deductibles in full and pay any co-insurance when using physicians and facilities outside the network (Wright, n.d.).This may also cause a problem when the patient needs to follow up. If that facility is out of network, it may be difficult for the provider to request medical records, while the records would be more accessible with other providers in network.
Reference:
Wright, T. (n.d.). What is a Gatekeeper PPO? retrieved from
https://finance.zacks.com/gatekeeper-ppo-9695.html