May 6, 1998
Most specialists don’t assume primary-care role for older patients even when they are the only source of care
Having a regular primary-care doctor — either a family physician or a general internist — may be good for your health.
A new study from the University of Washington shows that generalists are much more likely than specialists to act as primary-care providers for their elderly Medicare patients.
The study suggests there are advantages to patients who have a primary-care doctor as their regular physician, an approach at the center of most managed-care plans.
“It’s a question of how to design the best health-care system,” said lead author Dr. Roger A. Rosenblatt, professor of family medicine at the University of Washington School of Medicine. “Do you train more generalists or more specialists? Should you have physician coordinators of care? In light of the recent widespread criticism of managed care, we thought it was important to study what actually happens to patients who have no restrictions on their choice of doctors.”
Rosenblatt and colleagues examined the records of a population for which comprehensive data exists: Medicare patients. They did a cross-sectional study of all non-managed-care Medicare beneficiaries in Washington state, aged 65 and older, who made at least one office visit to a physician in 1994 and 1995. The patient population totaled 373,505.
The goal was to determine the extent to which individual specialties acted as primary-care doctors. Primary-care provision was defined as including the following elements: being the doctor seen most frequently by a patient (continuous care); taking care of patients for a broad spectrum of illnesses (comprehensive care); and administering influenza vaccines (preventive care).
There were major differences between the care given by primary-care doctors and that given by medical and surgical specialists. Although 15 percent of patients saw only specialists during the two-year study period, it was rare for specialists to actually assume the primary-care role. Specialists tended to restrict themselves to medical problems specific to their specialty. They rarely immunized their patients, even when they were the doctors seen most frequently.
The differences in immunization practices were particularly dramatic. Not only did the regular patients of primary-care doctors have a significantly higher immunization rate than the regular patients of medical and surgical specialties, but generalists were more than twice as likely as specialists to provide the immunization in their offices.
“This study does not argue that one specialty is superior to another,” said Rosenblatt. “There are critical roles for both specialists and generalists. The question is whether the current structure of care is optimal for elderly patients. Many never see a generalist physician. Patients without a primary-care physician may not be getting the breadth of care they need.”
Rosenblatt and colleagues cite an earlier study that concluded there is a “hidden system” of general medical care in which specialty physicians spend considerable time providing primary care. The current study demonstrates that while specialists are responsible for the majority of outpatient visits, they do not take the place of primary-care doctors.
The study does show that when specialists are the doctors seen most frequently by a given patient, they are more likely to provide a broader range of care. To a greater extent than other specialties, pulmonologists, rheumatologists, oncologists, general surgeons and gynecologists assume the generalist role for patients they see frequently.
“The data suggest that primary care means something quite different for most specialists than it does for most generalists,” the authors write. “Specialists tend to focus on the diagnoses that define their specialty. Although they may be the principal — and in some cases only — physician for a subset of their patients, they probably only rarely provide substantial amounts of care beyond the boundaries of their specialty.”
“Some specialists have said recently that they can do primary care as well as specialty care,” said Rosenblatt. “But this is not the best solution. We should train the appropriate number of specialists and the appropriate number of primary-care doctors.
“This study shows that there is value in having a physician coordinator of care — not to act as a gatekeeper, but to offer a wider range of diagnostic services, comprehensive care and preventive care.”
Co-authors are Drs. L. Gary Hart, Laura-Mae Baldwin and Ronald Schneeweiss of the UW Department of Family Medicine, and Dr. Leighton Chan of the Division of Clinical Standards and Quality, Health Care Financing Administration, Region X.
The research was supported by grants from the Robert Wood Johnson Foundation and the U.S. Public Health Service’s Office of Rural Health Policy and