Our study has several policy implications. Our results indicate that specialists vary in their attitudes toward the gatekeeping role of primary care physicians and that negative attitudes are not necessarily an immutable characteristic of being a specialist. Attitudes appear to be shaped at least in part by the specialists’ financial interest that may be threatened by restrictions on referrals and by the system in which they practice. Policies that promote alternatives to fee-for-service payment and shift specialists away from solo practice toward larger, organized group practice settings may also encourage them to adopt more positive attitudes about the role of primary care physicians as coordinators of care. Integrated work environments may generate a common sense of purpose, stemming in part from physical proximity to facilitate communication and cooperation.
Limitations
Several limitations of our study are worth noting. Our study was limited to physicians in California. Although California has one of the most competitive managed care markets in the United States and may exemplify trends occurring in other states with active managed care markets, results may not necessarily be generalizable to physicians working in other states. Our main study variable—attitudes toward primary care gatekeepers—is a subjective measure. The wording of our main study question specifically highlighted primary care physicians in a gatekeeper role. The response to this question is therefore not necessarily indicative of the attitudes of specialists toward primary care physicians in general. Interpretation of the word “gatekeeper” was left up to the respondent. Finally, as in all observational studies, causal inferences must be made with caution. We detected strong associations between payment method and practice setting and specialists’ attitudes toward gatekeepers. Although it is plausible that payment incentives and practice environment influence specialist attitudes, it is also possible that specialists who have different underlying values are attracted to different types of practice settings and payment arrangements. For example, salaried group-model HMOs may attract specialists who already have relatively favorable attitudes toward primary care gatekeeping, rather than (or in addition to) that culture promoting a more favorable attitude. Solo practice, in contrast, may attract physicians who are more independent and predisposed to perceive the gatekeeper role as adversarial.
Conclusions
In the US health care system gatekeeping remains controversial. Specialist ambivalence toward gatekeeper models may undermine the legitimacy of a more primary care–focused system. 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.18 Models of care that promote integration and coordination by primary care physicians without emphasizing a restricting role may decrease tensions among physicians. 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.19 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.
· Acknowledgments ·
This work was supported by the Bureau of Health Professions, HRSA (Grant 5 U76 MB 10001). The authors thank Dennis Keane, MPH, and Deborah Jaffe for their assistance with survey administration; Art Munger for assistance with manuscript preparation; Norman Hearst, MD, MPH, for his comments on early drafts; and the physicians who participated in the study.