Balancing Control and Care: Patients’ Perceptions of the Family Physician’s Dual Role as Gatekeeper and Case Manager in Israel
Hadar Goldshtein, Royi Barnea, Yossi WeissBackground
Family physicians combine gatekeeping and case‐management roles, regulating access to services while coordinating care, maintaining continuity and fostering trust. Less is known about how patients perceive this balance.
Objective
To examine patients’ perceptions of family physicians along a gatekeeper–case manager continuum and identify associated factors.
Methods
A cross‐sectional online survey was conducted in March 2025 among Israeli adults aged 21 years and older. Of 602 respondents, 575 reported knowing their family physician and were included. A theory‐driven questionnaire, developed and preliminarily evaluated for this study, assessed perceived gatekeeping and case‐management functions. Final indices included a nine‐item Gatekeeper Index and a ten‐item Case Manager Index. Analyses included exploratory factor analysis, reliability testing, bivariate analyses and multivariable regression. Missing covariates were addressed using multiple imputations among 411 respondents with observed CM_relative scores. Exploratory latent‐profile analysis and multinomial regression examined perceived role patterns and their correlates.
Results
Both indices showed high internal consistency ( α = 0.883 for Gatekeeper; α = 0.935 for Case Manager), and exploratory factor analysis supported a two‐factor structure. Case‐management attributes were perceived more strongly than gatekeeping attributes (mean CM_relative score = 61.21 index points, SD = 11.56). In complete‐case multivariable analysis ( N = 355), higher CM_relative scores were associated with satisfaction ( B = 7.42), willingness to recommend ( B = 6.26) and remaining for personal reasons ( B = 6.15); referral refusal was associated with lower scores ( B = −9.42; all p < 0.01). The four main associations persisted after multiple imputation. An exploratory three‐profile solution was retained, with referral refusal associated with gatekeeper‐dominant versus mixed membership.
Conclusions
Patients perceived case‐management attributes more strongly than gatekeeping attributes. Relational experiences and referral interactions appear central to how patients interpret family physicians’ dual role.
Lived Experience or Public Contribution
Patients and the public were not involved in the study. The findings were derived from anonymous patient‐reported survey data and may inform future patient‐centred primary care research.