Gatekeeper policy along with health insurance programs is a critical policy in orienting a health system towards primary health care [18, 19]. There have been a substantial amount of researches about the effect of gatekeeping  on health- and patient-related outcomes , satisfaction with care , quality of care  and utilization of health care , but few studies about patients’ acceptance of gatekeeping were conducted. Our study is an important supplement in the research field of gatekeeper policy.
The research was conducted among the population covered by GIS, among whom the policy had been implemented for many years, and the differences between the attendances of patients to CHC for treatment owing to mandatory reimbursement provision in the two groups suggested that the compulsory policy about reimbursement might be associated with patients’ acceptance. In addition, we used the EUROPEP scale , an internationally-accepted questionnaire with high reliability and validity (Cronbach’s α = 0.96 and KMO = 0.96), to assess patient satisfaction with CHS, and the distribution differences of satisfactions with CHS suggested that patients’ satisfaction with CHS might be also associated with their acceptance (Additional file 1).
Furthermore, we conducted the regression analysis to examine the above speculations, and the results suggested that attendance to CHC for treatment owing to mandatory reimbursement provision was independently associated with patients’ acceptance of gatekeeper policy, when controlling for patients’ satisfaction and socio-demographic characteristics. It implied that the policy-maker should pay more attention to the effect of mandatory provision on patients’ acceptance of gatekeeper policy. Indeed, the mandatory reimbursement provision restricted patients’ choices in a certain extent, and thus they may be not willing to accept the gatekeeper policy. However, the policy-makers may have to compare the advantage and disadvantage of mandatory provision, simplifying the procedure of reimbursement or making the referral channels unimpeded may reduce the impact effectively, but they need further verification.
Another important finding was that not all dimensions of patients’ satisfaction with CHS affected their acceptance of the policy. Generally, when a patient was asked “why he or she was not subject to gatekeeper policy”, he/she may answer “I’m not satisfied with CHS”, however, it was complex and multidimensional in the diagnostic and therapeutic procedures for patients’ treatment in CHCs. Therefore, to determine the aspect that played a more prominent role in affecting patients’ acceptance was of great importance. Our study suggested that only the aspects of medical care and organization of care were positively associated with acceptance of policy. Therefore, managers and general practitioners should pay more attention to the two aspects of care when implementing the gatekeeper policy, especially in the early stage of implementation.
Some limitations should also be acknowledged in the study. First, the potential influencing factors of patients’ acceptance of policy are possibly more than those we investigated, such as patients’ experiences of referral. Second, the patients’ acceptance of the gatekeeping policy was assessed by a single item, and the acceptance-related scale with more questions should be developed in further studies. Third, our study was based on patients with GIS who may be more subjected to the policy, and therefore, the conclusion should be cautious to apply to populations with other health insurance schemes. Finally, the study did not involve the reasons why the mandatory reimbursement provision affects the patients’ acceptance. Therefore, more studies are needed to include more potential factors influencing patient acceptance with the gatekeeper policy, especially those factors for which specific interventions could be devised to determine how the mandatory reimbursement provision influence patient acceptance, and then to improve patients’ acceptance of the policy.