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Objective: Private health insurance is becoming more common in Norway. The aim of this study was to investigate GPs' opinions on private health insurance, and their experiences from consultations where health insurance can affect decisions about referring. Design: A web based cross-sectional survey. Setting: Norwegian general practice. Subjects: All GPs in Norway were in 2019 invited to participate in an online survey. Main outcome measures: The GPs' opinions and experiences regarding health insurance were reported as proportions. Multiple logistic regression was used to test associations between how frequently GPs refer patients without further considerations and variables concerning their characteristics, opinions, and experiences. Results: Of 1,309 GPs (response rate 27%), 93% stated that private health insurance raises the risk of overtreatment and 90% considered such insurance to contribute to inequality in health. Frequently being pressured to refer in the absence of a medical indication was reported by 42%. Moreover, 28% often or always chose to refer patients without further consideration, and this was associated with perceptions of pressure with an adjusted odds ratio (AOR) of 3.80, 95% confidence interval (CI) 2.73–5.29, and unpleasant reactions from patients following refusals (AOR 1.63, 95% CI 1.14–2.33). Conclusion: Although most participating GPs associated private health insurance with overtreatment and inequality in health, more than one in four choose to refer without further consideration. GPs' experience of pressure to refer and negative reactions from patients when they consider referrals not to be medically indicated, raises the risk of medical overuse for patients holding private health insurance. KEY POINTS: Although most GPs had negative opinions regarding private health insurance, more than one quarter frequently referred insurance holders without further considerations. Perceived pressure and negative reactions from patients were associated with accommodating requests rather than acting as a gatekeeper. Private health insurance challenges the gatekeeping role of GPs in Norway and raises the risk of medical overuse. [ABSTRACT FROM AUTHOR]

Background: Requests from patients that are regarded by GPs as unreasonable are a source of conflict between GPs and patients. This makes gatekeeping challenging, as GPs negotiate a struggle between maintaining the doctor-patient relationship, protecting patients from the harms of medical overuse and acting as stewards of limited health care resources. More knowledge of how GPs can succeed in these difficult consultations is needed.Objective: To explore Norwegian GPs' perceptions of conditions that can promote their ability to act as gatekeepers when facing patient requests which they consider 'unreasonable'.Methods: A qualitative study based on three focus groups with Norwegian GPs conducted in 2019, exploring consultations in which the patient made a seemingly unreasonable request, but the GP was able to navigate the consultation in a clinically appropriate manner. Thematic cross-case analysis of verbatim transcripts from the focus groups was carried out using Systematic Text Condensation.Results: The analysis revealed three major themes among the conditions that the GPs considered helpful when faced with an 'unreasonable' patient request: (i) professional communication skills; (ii) a long-term perspective; (iii) acknowledgement and support of GPs' gatekeeping role among peers and from authorities.Conclusion: Professional communication skills and relational continuity need to be prioritized for GPs to maintain their role as gatekeepers. However, support for the gatekeeping role within the profession as well as from society is also required. [ABSTRACT FROM AUTHOR]