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In the United States, health care reform has been one of the top issues on the minds and in the hearts of citizens and lawmakers alike. While health care reform is a vast issue involving many possible outcomes, it is an issue that may not see resolve for quite some time. One of the current issues outlying health care reform is cost, or budget control. Currently, some managed care plans require that patients receive the approval of primary physicians before being granted permission and funding to see a specialist (Sultz and Young, 2006), a practice known as gatekeeping. This is a practical way of keeping the inflated costs of specialty care and hospitalization to a minimum, but can be, and has been troublesome for physician and patients in the past.

Gatekeeping is widely used in healthcare organizations and governments throughout the world, which proves that is an effective and necessary way of keeping costs under control. In fact Bradford L Kirkman-Liff (1994) mentions that countries such as Italy, the United Kingdom and Denmark have been using this approach far longer than the United States (p. 33). The reason for its criticism may lie in the manner in which HMOs were influencing primary physicians’ decisions.

In the recent past, much controversy in regards to gatekeeping arose because “the gatekeeper’s own reimbursement was often linked to the number of referrals made to specialists” (Sultz and Young, 2006). Managed care plans were compromising the quality of care patients received when they penalized, or even reduced the income of primary caregivers who cost the company more money through their referrals. Thus the question presented by Harold Pollack and Richard Zeckhauser (1996) is; “How can a central budgetary authority, who cannot examine individual patients but can observe overall costs, induce gatekeepers to approach socially optimal decisions?” (p. 651). In other words, how can gatekeeping be effective in reducing cost...