Primary care without permission

Who owns the relationship as the gatekeeper role fades?

For decades, primary care has been the gatekeeper of American medicine. PCPs were the trusted first contact, the coordinator of referrals, and, frequently, the arbiter of necessity.

But that construct is eroding in the face of new consumer behavior, technology, and market design, prompting health plan and provider system leaders to address the uncomfortable question of what happens when the gate no longer exists, or when the gatekeeper is an algorithm?

The decline of the gatekeeper model

Consumers are no longer waiting for permission to enter the healthcare system. They are self-navigating. Urgent care centers, retail clinics, asynchronous visits, and AI triage tools have turned the front door into a revolving set of entrances. Patients are making decisions based on immediacy, convenience, and affordability, not continuity. In this world, the traditional PCP is no longer the default first stop but one of many options in a fluid care ecosystem. "My doctor" is being replaced by “my access channel.”

For payers and providers, this means the very logic of access and attribution must be reimagined. Primary care can no longer be defined by where care begins, but by how well it is connected. The future lies in building a coordinating hub that integrates virtual, digital, and team-based care into a seamless experience.

When coordination replaces control

The gatekeeper model was originally designed to manage cost and utilization. But it also preserved hierarchy: physicians as traffic controllers, specialists as downstream destinations, and patients as passive travelers. That structure aligned with a fee-for-service economy built on volume and control.

Today’s reality is different. AI, nurse practitioners, and virtual-first platforms are reshaping entry points, while reimbursement models reward access, satisfaction, and total cost management. Clinging to the gatekeeper logic, which positions the physician as a bottleneck and broker of risks, making primary care irrelevant in the very system it helped build.

To remain central to value creation, primary care must pivot from permission to orchestration, from controlling entry to curating the care experience. That means using digital intelligence to anticipate needs, deploy the right team member, and ensure continuity across multiple care channels.

The primary care physician’s role becomes less about “seeing first” and more about “seeing the whole.”

Virtual-first or system-first?

Critics fear that the erosion of the primary care gatekeeper role–and especially the emergence of virtual, chat-based, and AI-enabled options–risks fragmenting relationships and turning health into a series of disconnected transactions.

I believe it can just as easily expand the clinician’s reach if systems are willing to integrate it. The question isn’t whether virtual and AI tools will dominate; they already have. The question is whether providers will design them to feed the longitudinal record and reinforce continuity, or allow them to operate as competitors siphoning off volume and loyalty.

The systems that win will build system-first, not site-first models of access, where the digital front door routes patients intelligently to the most appropriate next step, whether that’s an in-person visit, a remote nurse follow-up, or a specialist e-consult.

The strategic reckoning

Primary care is at an inflection point. If the primary care model remains anchored to the gatekeeper role, it risks being bypassed entirely by faster, cheaper, and more responsive platforms. If it evolves into a relationship and coordination engine, it can finally fulfill its promise of continuity, equity, and value.

The uncomfortable question for every health system and payer is this:

Are we ready to evolve the hierarchy, billing structures, and identity built around the gatekeeper model, and replace them with a networked, AI-augmented, consumer-defined ecosystem that prizes coordination over control?

That is not merely a redesign of care delivery. It is a redefinition of what it means to own the relationship in a post-gatekeeper world.