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Source: Abby Sinnott
415-476-2557
01 December 2001
UCSF studies specialists' attitudes toward primary care physician referrals
A recent study at the University of California, San Francisco assessed specialists' attitudes toward primary care physicians in the gatekeeper role, finding the attitudes are influenced by practice settings and by financial interests that may be threatened by referral restrictions.
"Health systems with strong foundations in primary care appear to produce better patient outcomes than systems that do not promote such primary care elements as continuity and coordination of care," said lead author Eduardo Pena-Dolhun, MD, UCSF assistant professor in the department of Family and Community Medicine.
The study, scheduled for publication in the December 1 issue of The Journal of Family Practice, is based upon responses from 979 physicians who completed the survey. Salaried physicians as opposed to specialists in solo practice had a somewhat more favorable attitude toward gatekeepers as did physicians with a greater percentage of income derived from capitation.
Practice setting and payment method were among the strongest predictors of attitudes toward gatekeepers. Specialists in solo practice exhibited the most negative attitudes, but attitudes were much more positive among specialists working in large practice settings and especially among physicians working in health maintenance organizations. Physicians responding came from specialties including cardiology, endocrinology, gastroenterology, neurology, ophthalmology, orthopedic surgery, and general surgery. Specialists in solo practice exhibited the most negative attitudes. I think that this would be a good place to talk about the financial differences, i.e., fee-for-service v. salary v. captitation.Salaried physicians demonstrated the most favorable attitudes toward gatekeepers and fee-for-service specialists the least favorable attitudes. Those specialists classified as capitated were on average neutral in their views of gatekeepers. Female specialists and those who were younger also had significantly more favorable gatekeeper attitude scores.. This last point is true, but we did not emphasize it because of the relatively smaller numbers in these categories. But I am fine with leaving it in. I think that we definitely need to say something specifically about the financial incentives since it is a key issue. "Although there is widespread support among those surveyed for many of the core values of primary care, there is also apprehension about policies that insist that primary care physicians authorize access to specialists, particularly when primary care physicians or commercial health plans may profit financially by economizing on specialty services," said Pena-Dolhun.
The researchers suggested that organizational structures and payment methods that minimize conflict between primary care physicians and specialists will be essential to the further development of an integrated health care system. "Policies that promote alternatives to fee for service may generate a common sense of purpose among primary care physicians and specialists," Pena-Dolhun said. "Future health policies will need to consider how to encourage cooperation between primary care physicians and specialists to best meet the needs of the patient."
Work on this study was supported by the US Bureau of Health Professions. Co-authors include Kevin Grumbach, MD, vice-chair of UCSF Family and Community Medicine; Karen Vranzian, MA, senior statistician, General Internal Medicine at SFGH Medical Center; Dennis Osmond, PhD, UCSF associate adjunct professor of Epidemiology at SFGH Medical Center; and Andrew B. Bindman, MD, chief, General Internal Medicine at SFGH Medical Center.
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