Gatekeeping under fire as docs push principal’ care
Specialists seek PCP role for chronically ill
The much-maligned "gatekeeper" model of medicine may be facing its greatest challenge yet from specialists who say they are most capable of managing the care of patients who have chronic illnesses. These physicians are promoting a system of "principal" care, in which specialists with training in internal medicine can serve in a dual role for some patients.
Meanwhile, health plans responding to the marketplace and to access concerns expressed by patients are offering more products that allow direct access to specialists. For example, United HealthCare’s "open access" arrangement has worked well for the Minneapolis-based managed care organization, according to Robert Pope, MD, medical director for United HealthCare of Georgia. (For more information on these plans, see Physician’s Managed Care Report, December 1996, p. 139.)
"Choice is clearly the dominant word in the medical marketplace now," says Alan R. Nelson, MD, executive vice president of the American Society of Internal Medicine (ASIM) in Washington, DC, which has many members with training both in internal medicine and a subspecialty.
Yet managed care organizations view the gatekeeper (or primary care provider) model as a key element of their cost-saving strategy. According to a 1995 survey by the Society, many managed care officials worry that a combined primary care/specialist physician would self-refer, or that allowing physicians to be listed in networks for both roles would raise costs.1
Research shows conflicting results
Current research further confuses the issue. A study by researchers at the Johns Hopkins School of Public Health in Baltimore demonstrated a savings of 53% when patients first saw a primary care physician for new medical problems.2 A study of claims data of patients with diabetes and hypertension reported no differences in outcomes if their care was handled by primary care physicians or specialists.3
Yet specialists can point to other research that shows specialized expertise does make a difference. Notably, studies have shown that in the care of specialists, stroke and cardiac patients have a higher rate of survival4,5 and kidney patients begin dialysis treatment more promptly.6
In a review of the literature for a book on quality measurement and its impact, Jonathan Seltzer, MD, MBA, executive director of Thomas Jefferson University’s Office of Health Policy and Clinical Outcomes in Philadelphia, found evidence on both sides of the argument.
"In cardiology, you can find papers that show that for post-myocardial infarction, cardiologists use more of the recommended medicines than non-cardiologists," he says. "There are [other] studies that show in an uncomplicated myocardial infarction, care of a primary care physician is as effective as [that of] a cardiologist."
Research may not ultimately resolve this debate, he says. "It may be an area where market forces will help answer the question," he says.
Internist forced to choose role
For Nelson, the gatekeeper-vs.-specialist struggle is a very personal one. Although he had practiced both as a primary care physician and consulting endocrinologist in Salt Lake City for 27 years, managed care organizations forced him to choose between the two roles.
"It made sense for me as an endocrinologist to provide the full range of primary care services for my patients," says Nelson. "Even though they may have come to me for an endocrinology problem, they wanted to stay with me to manage their general internal medicine care."
Nelson also served as a general internist for patients without endocrine problems, and as a consultant to other primary care physicians in the area of endocrinology.
When some managed care organizations forced Nelson to make a choice about how he would be listed in their networks, he chose endocrinology. (In other cases, the MCO makes the decision, Nelson notes.) Although he and some of his diabetic patients argued that the complexity of their cases demanded monitoring by someone with his expertise, Nelson was unable to circumvent the policy.
For example, Nelson had patients on sophisticated insulin pumps. He says he had to arrange for another internist to see them, even though the internist didn’t know as much about the insulin pump.
What bothers Nelson most is that plans may insist on a division between primary care and specialty care because it is administratively simpler to maintain separate physician panels. The ASIM position is that physicians shouldn’t have "arbitrary restrictions" placed on their practice of medicine.
Boosting skills vs. defending turf
The debate over who should manage patient care shouldn’t become a turf battle, but should focus on what skill or knowledge base is required to handle various chronic diseases, says David Lanier, MD, a family physician and senior policy analyst at the Center for Primary Care Research of the Agency for Health Care Policy and Research in Rockville, MD.
"You can’t say generically that every primary care provider knows this much and only this much," he says. "What you do is reduce it to the lowest common denominator of every primary care provider. One provider may have great skills in handling cardiac cases.
"If we find out there is a knowledge gap among primary care clinicians about how they can improve the outcomes of their patients either by earlier referral [to specialists] or doing certain tests, that’s useful for us to know," he says.
Last year, the agency held a conference on "Research at the Interface of Primary and Specialty Care," and in December the agency funded eight research projects to examine the quality and cost impact of referral patterns.
For now, Lanier is not convinced that "principal care" is the way to go. "My concern about it is that you classify a person with diabetes as a diabetic," he says. "She may also get breast cancer, she may be depressed, she may have other problems that the endocrinologist may not be prepared to handle."
There aren’t enough cardiologists’
The internal medicine society states that in "principal care," subspecialists should meet all of the managed care organization’s credentialing criteria for its primary care panel. Not every specialist may want or be able to meet those criteria, such as requirements to offer after-hours coverage and to perform pelvic examinations on female patients. Conversely, not every cardiac patient will be able to find a cardiologist able and willing to monitor his or her overall care, Lanier notes.
"There are not enough cardiologists to go around nor should there be to take care of everybody [on an ongoing basis] who has a heart attack in the United States," he says.
References
1. American Society of Internal Medicine. Managed Care Survey of HMOs. Washington, DC; 1995.
2. Forrest CB, Starfield B. The effect of first contact care with primary care clinicians on ambulatory health care expenditures. J Fam Pract 1996; July:40-48.
3. Greenfield S, et al. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. JAMA 1995; 274:1436-1444.
4. Mitchell JB, et al. What role do neurologists play in determining the costs and outcomes of stroke patients? Stroke 1996; 27:1937-1943.
5. Jollis JG, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med 1996; 335:1880-1887.
6. Ifudu O, et al. Excess morbidity in patients starting uremia therapy without prior care. Presented at the annual meeting of the American Society of Nephrology. New Orleans; November 1996.
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