Abstract
BACKGROUND: Ambulatory healthcare in Germany is under pressure due to the increasing need for care, medical progress and a shortage of specialist personnel. Making general practitioners mandatory gatekeepers is on the political agenda aiming at more targeted use of specialist care and improved quality of care. OBJECTIVE: The study investigated how many persons in the statutory health insurance (SHI) currently consult specialists or psychotherapists without a referral and what additional burden a primary care system would place on general practitioners if these cases also had to be managed by them. MATERIAL AND METHODS: Based on nationwide physician billing data for all SHI patients in 2023, cases of adult SHI patients were selected in which a general practitioner contact fee ("hausärztliche Versichertenpauschale, VP") or a specialist or psychotherapeutic contact fee ("fachärztliche/psychotherapeutische Grundpauschale, GP") was claimed. Specialist or psychotherapy cases without a documented referral were considered as potentially uncontrolled. Various scenarios were considered to calculate the potential additional burden resulting from increased general practitioner control. RESULTS: Out of 59 million insured adults 33.2 million visited a specialist or psychotherapist at least once without a documented referral. This was associated with 17-102 million potentially uncontrolled specialist or psychotherapy cases. If these had to be additionally managed by general practitioner in a gatekeeper system, this would imply approximately 335-2000 additional contacts per general practitioner per year, depending on the scenario. CONCLUSION: The actual additional burden on general practitioner depends largely on the specific design of the primary care system. A moderate additional burden is likely and the decisive factor is a binding of patients for longer periods to the chosen primary care practice.