OBJECTIVE: We surveyed specialist physicians in California to determine whether their attitudes toward primary care gatekeepers differed depending on how the specialists were paid and the settings in which they practiced.
STUDY DESIGN: We performed a cross-sectional survey using a mailed questionnaire. The predictors of specialist attitudes toward gatekeepers were measured using chi-square, the t test, and regression analyses.
POPULATION: A probability sample of 1492 physicians in urban counties in California in the specialties of cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, and orthopedics was used.
OUTCOMES: We assessed specialists’ attitudes toward primary care physicians in the gatekeeper role. A summary score of attitudes was developed.
RESULTS: A total of 979 physicians completed the survey (66%). Attitudes toward primary care physicians were mixed. Relative to nonsalaried physicians, those who were salaried had a somewhat more favorable attitude toward gatekeepers (P=.13), as did physicians with a greater percentage of income derived from capitation (P=.002).
CONCLUSIONS: Specialists’ attitudes toward the coordinating role of primary care physicians are influenced by the setting in which the specialists work and by financial interests that may be threatened by referral restrictions. Policies that promote alternatives to fee for service may generate a common sense of purpose among primary care physicians and specialists.
A well-functioning health system requires effective cooperation between primary care and specialist physicians. Tensions between these types of physicians seem to be increasing because of managed care plans, many of which rely on primary care physician gatekeepers to authorize visits to specialists, interrupting the direct access to specialists that many insured Americans expect. Researchers have investigated how gatekeeper policies are affecting primary care physicians and patients.1-11 However, little research has explored the attitudes of specialist physicians toward the changing role of their primary care counterparts.12,13 Some specialists appear to be troubled by gatekeeper policies, viewing primary care physicians as their competitors rather than their colleagues.14-17
Professional organizations representing specialists have advocated for “direct access” legislation that would require health plans to permit patients to visit a specialist without first contacting a primary care physician. These groups have promoted this type of legislation as something that is important for ensuring quality of care. However, more than the patient’s welfare may be at stake in this policy debate. Gatekeeper policies that potentially reduce use of specialist services may be reducing specialist income, particularly when those physicians are paid on a fee-for-service basis.
We surveyed specialist physicians in California to investigate their attitudes toward primary care physicians acting in a gatekeeper role. We explored whether specialist attitudes differed depending on the setting in which the physician practiced and how the physician was paid. We hypothesized that those specialists compensated mainly on a fee-for-service basis would be more financially threatened by gatekeeper policies and would therefore have less favorable attitudes toward primary care physicians in this role. We also hypothesized that specialists working in larger group practice settings would have more collegial relationships with primary care associates that would promote more favorable attitudes.
Methods
In 1998 we mailed self-administered questionnaires to specialist physicians practicing in the 13 largest urban counties in California (Alameda, Contra Costa, Fresno, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Sacramento, San Francisco, San Mateo, Santa Clara, and Solano). The study counties contained 79% of California’s practicing specialist physicians and 79% of the state’s population. The physicians were identified from the American Medical Association (AMA) physician masterfile. The masterfile contains continuously updated information on all US allopathic physicians and many osteopathic physicians, including those who are not AMA members. To be eligible for the survey, physicians had to be listed as providing direct patient care, not in training, and not employed by the federal government.
Specialists were sampled who listed their primary specialty as cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, or orthopedics. These specialties were chosen to provide a broad spectrum of both surgical and medical office-based subspecialties, and to represent most of the largest non–primary care office-based specialties in California. Physicians were selected using a probability sample stratified by specialty (250 physicians in each specialty) and physician race/ethnicity (nonwhite physicians were oversampled). To develop a valid set of questions, we first pilot-tested our questionnaire on a group of 10 specialty physicians. The questionnaire included items on physician demographics, practice setting, number of physicians in the practice, and modes of payment. For analyzing payment modes, physicians were first categorized as salaried or nonsalaried; those that were nonsalaried were asked to indicate the percentage of their practice income derived from fee-for-service and capitated payment.
The questionnaire included a series of items about specialists’ attitudes toward primary care physicians in the gatekeeper role. The specialists were asked to respond to each of the following statements with “strongly agree,” “agree,” disagree,” or “strongly disagree”: “The involvement of a primary care gatekeeper in the care of the patients I see: (1) undermines my relationships with patients; (2) makes it more difficult to order expensive tests or procedures; (3) decreases freedom to make clinical decisions; (4) increases the likelihood that patients will receive preventive care; and (5) improves the coordination of patient care.” For simple descriptive analysis of the individual gatekeeper items, responses were collapsed into dichotomous categories of “agree” or “disagree.”