Incentivising patient pathways in outpatient care: A review of gatekeeping and cost-sharing policies across the OECD

Improving the efficient use of scarce resources is a key priority in many OECD countries to ensure the long-term sustainability of health spending. One option is to address the demand side by incentivising patients’ care-seeking behaviour. In this context, gatekeeping – a policy tool through which general practitioners (GPs) or other primary care physicians control access to specialist care, and cost-sharing – arrangements requiring patients to contribute financially to the cost of care, are two instruments frequently discussed. Both policy tools are widely applied across the OECD and may also pursue objectives beyond improving efficiency. Focusing on the outpatient sector, this Working Paper provides a stocktake of which OECD countries have these policies in place and how they are designed. It also reviews evidence on how these policies affect health care spending, efficiency and health outcomes. This is complemented by six country case studies that describe the implementation of gatekeeping and cost-sharing arrangements in detail and identify factors that can influence their impact on health system performance. These include the availability of GPs, how GPs are incentivised to deliver services, and whether patients can bypass gatekeeping pathways.