ABSTRACT. Evaluation studies on the gatekeeping role of primary care physicians exist for a variety of countries but provide mixed evidence on utilization and quality of care as well as costs. We access claims data of a major German statutory health insurance company to evaluate the physician-centered gatekeeping program. The data allows controlling for patients’ characteristics in the year before opting for the gatekeeping contract. In contrast to previous studies, we are able to draw on multiple identification strategies. We exploit variation in the regional provision of gatekeeping in an instrumental variable framework. We also analyze physician fixed effects based on the observation of patients opting for one of two different contracts within the same physician’s office. Compared to non-gatekeeping, we find that the gatekeeping contract yields a somewhat higher coordination of care, improved quality (regarding prevention and avoidance of hospitalization) but also higher ambulatory costs. Effects are largely robust between identification strategies.

Keywords: primary healthcare; gatekeeping; healthcare quality; coordination of care; PCPs

How to cite: Hofmann, Sarah M., and Andrea M. Mühlenweg (2017), “Primary Care Physicians as Gatekeepers in the German Healthcare System: Quasi-experimental Evidence on Coordination of Care, Quality Indicators, and Ambulatory Costs,” American Journal of Medical Research 4(2): 47–72.

Received 21 February 2017 • Received in revised form 9 May 2017
Accepted 10 May 2017 • Available online 30 May 2017


WifOR Darmstadt;
Universität Duisburg-Essen
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WifOR Darmstadt;
Leibniz Universität Hannover
(corresponding author)


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