Competition, Gatekeeping, and Health Care Access

We study gatekeeping physiciansiÌ referrals of patients to specialty care. We derive two theoret- ical results when competition in the physician market intensiÖes. First, physicians refer patients to specialty care more often due to competitive pressure. Second, physicians earn more by treat- ing patients themselves, so refer patients to specialty care less often. We assess empirically the overall e§ect of competition with data from a Norwegian survey in 2008-9 and Statistics Norway. From the data we construct three measures of competition: the number of open primary physician practices with and without population adjustment, and the HerÖndahl-Hirschman Index. The em- pirical results suggest that competition has negligible or small positive e§ects on referrals overall. Our results do not support the policy claim that increasing the number of primary care physicians reduces secondary care.