Center for Studying Health System Change

	David Blumenthal
	Peter Kemper
	Marie C. Reed
	Robert F. St. Peter

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	How Physician Organizations Are Responding to Managed Care May 1999 Issue Brief No. 20
	Access to Specialists: Fall 1997 Data Bulletin No. 02

The Scope of Care Expected of Primary Care Physicians:

Is it Greater than it Should Be?

Issue Brief No. 24
December 1999
Robert F. St. Peter, Marie C. Reed, Peter Kemper, David Blumenthal

he United States has long relied on specialist physicians more heavily than other countries, and some policy experts have repeatedly recommended that the share and role of primary care physicians (PCPs) be increased as a way of providing cost-effective care. The growth of managed care, changing practice arrangements and new medical technology are forces that may be increasing the role of PCPs. This Issue Brief reports findings published in the New England Journal of Medicine showing that many physicians believe the scope of care provided by PCPs without referral to specialists is increasing. Moreover, almost a quarter of PCPs report that the scope of care they are expected to provide is greater than it should be. The likelihood of PCPs’ concern is related to specific managed care techniques, practice size and specialty, among other factors.

• The Scope of Care
  
• A Shift in Roles and Perceptions
  
• What Factors Underlie Physicians’ Concerns?
  
• Implications
  
• Data Sources

The Scope of Care

here has long been an interest in enhancing the role of PCPs, particularly among some policy experts and associations representing primary care doctors. Proponents argue that greater reliance on PCPs will reduce unnecessary or inappropriate use of expensive specialty services, and patients will receive better, more cost-effective care. Managed care plans and physician organizations have developed a variety of mechanisms to expand the role of PCPs, including the use of gatekeeping, practice profiles and financial incentives. These techniques may affect the scope of care provided by PCPs-that is, the complexity or severity of patient conditions for which PCPs provide care without referral to specialists. At the same time, some of the advances in diagnostic and treatment options also have contributed to expansion of the scope of care provided by PCPs.

Some patients and physicians have raised concerns about efforts to rein in the use of specialty care out of fear that the techniques used may inappropriately restrict access to specialists. Many states have responded to these concerns by enacting legislation enabling patients to choose a specialist as their PCP and to see certain specialists on a recurring basis after an initial referral from a PCP. As part of patient protection legislation, Congress is considering these specific measures as well as certain limits on financial incentives that may reduce specialist use. Managed care plans are also responding to the concerns; several have developed open-access plans that allow patients varying degrees of autonomy in seeking specialty care.

This study provides the first systematically collected information on change in PCPs’ scope of care and physicians’ concern about its appropriateness.

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A Shift in Roles and Perceptions

ccording to physicians, the relative role of PCPs and specialists is changing. Thirty percent of PCPs and 50 percent of specialists reported that the scope of care provided by PCPs has increased during the past two years (see Figure 1).

Physicians were also asked about the appropriateness of PCPs’ scope of care. Specifically, PCPs were asked whether they felt that the complexity or severity of patients’ conditions for which they were currently expected to provide care without referral was greater than it should be, about right or less than it should be. Nearly three in four PCPs reported that the scope of care expected of them was about right (see Figure 2). However, nearly one in four reported that these expectations were greater than they should be.

In addition, specialists were asked whether the complexity or severity of patients’ conditions at the time of their referral by PCPs was greater than it should be, about right or less than it should be. Thirty-eight percent of specialists reported that the complexity or severity at the time of referral was greater than it should be, 53 percent said it was about right and 9 percent said it was less than it should be.

Figure 1
Percent of Physicians Reporting that PCPs’ Scope of Care Has Increased in the Past Two Years

Figure 2
PCPs’ Assessments of the Appropriateness of the Scope of Care They Are Expected to Provide

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What Factors Underlie Physicians’ Concerns?

ccording to the study findings, which controlled for physician characteristics, market and other factors, PCPs’ concerns about the appropriateness of the scope of care expected of them is associated with a number of factors:

• The single most significant factor was whether PCPs reported that their scope of care had increased over the last two years. PCPs reporting that it had increased were more than twice as likely as those reporting that it had not increased to say that the scope of care they were expected to provide was greater than it should be (see Figure 3a).
• Although we did not find that total revenue from managed care (broadly defined to include preferred provider organizations as well as health maintenance organizations) was related to a greater likelihood of PCPs’ expressing concern, we did find a relationship with specific aspects of managed care. PCPs in practices that received some capitated revenue were more likely than those in practices with no capitated revenue to say that they were concerned about the appropriateness of the scope of care expected of them (see Figure 3b). Participation in gatekeeping arrangements and the extent of that participation also were associated with expression of concern (see Figure 3c).
• PCPs in smaller practices generally were more likely than those in larger practices to say that they were concerned about the complexity or severity of patients’ conditions for which they were expected to provide care without a referral (see Figure 3d).
• Family and general practice physicians were less likely than general internists and pediatricians to express concern about the scope of care expected of them.

Figure 3a
By Change in Scope of Care in Past Two Years

Figure 3b
By Percent of Physician Practice Revenue from Capitation

Figure 3c
By Percent of Patients in Gatekeeping

Figure 3d
By Practice Type

HSC Community Tracking Study Physician Survey, 1996-1997

Implications

sizable minority of both PCPs and specialists report concern about PCPs’ scope of care. The study suggests what may lie behind PCPs’ concern about the scope of care expected of them.

Gatekeeping and capitation are associated with greater likelihood of concern, which suggests that the use of these techniques to control unnecessary use of specialists may shift the boundary between PCPs and specialists and raise PCPs’ concern. However, the study did not find evidence that managed care without gatekeeping or capitation raises the level of concern.

Physicians in small practices are more likely to express concern than those in large practices. The availability of a range of formal and informal support from colleagues, such as "curbside" consultations, appears to have an important effect on PCPs’ level of comfort with the scope of care expected of them. The trend toward practicing in larger groups may eventually mitigate some physicians’ concerns about scope of care. Indeed, as the complexity of care increases, the role of practice setting in affecting the practice of medicine may become more important.

PCP concern is pervasive across all PCP subgroups examined. Even among those groups with the lowest likelihood of concern-those that did not perceive an increase in scope of care, did not have gatekeeping responsibility or practice in large groups-16 percent in each group expressed concern. This suggests that unmeasured factors, such as the growing complexity of medicine, account for some of the concern. Some discomfort among physicians may be inevitable as technology changes. Moreover, some of the physician concern may be transitional as PCPs adjust to their changing role. This possibility is supported by the study finding that physicians who said that their scope of care had increased were more likely to express concern.

In any case, PCPs should be adequately prepared for their expanding role, no matter whether it is due to managed care, the increasing complexity of care or other factors. In fact, the study found that specialty and years practicing medicine were associated with the level of PCP concern, suggesting that training and experience affect PCPs’ capacity to expand their scope of care.

Finally, from survey data we do not know whether physicians’ concerns about scope of care reflect poor clinical quality; assessing that would require measures based on a review of medical records. However, physicians’ concern about appropriateness raises the possibility that quality is affected. This underscores the importance of measuring quality directly and monitoring the appropriateness of access to specialists.

In summary, concern about appropriateness of PCPs’ scope of care merits attention from public and private policy makers, who may consider a range of responses. Among them are more intensive efforts to monitor quality of care, particularly access to appropriate specialty services, and training and continuing education of PCPs.

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Data Sources

his Issue Brief is based on data from the Community Tracking Study Physician Survey, a nationally representative telephone survey of nonfederal, patient care physicians conducted in 60 communities. PCPs were oversampled. The survey contains observations from more than 12,000 physicians.

Interviews for the survey took place between July 1996 and August 1997, with a response rate of 65 percent. Information about the specific samples and methods used in the analysis can be found in the article cited on page 4. Data in Figure 3 are estimates based on the multivariate model in that article and control for market, years in practice, other physician characteristics and the factors reported in the figure.

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A sizable minority of both PCPs and specialists report concern about PCPs’ scope of care.

Journal Article

This Issue Brief is adapted from "Changes in the Scope of Care Provided by Primary Care Physicians" by Robert F. St. Peter, Marie C. Reed, Peter Kemper and David Blumenthal, which appeared in the New England Journal of Medicine, Vol. 341, No. 26 (December 23, 1999).

Upcoming HSC Publications

• Local Innovations: Managed Care for the Uninsured
• Insolvency of Risk-Bearing Providers: Policy Issues and Responses
• Comparing HMOs to Other Plans: Access, Service Use and Satisfaction

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ISSUE BRIEFS are published by Health System Change.

President: Paul B. Ginsburg
Director of Public Affairs: Ann C. Greiner
Editor: The Stein Group