The Scope of Care Expected of Primary Care Physicians:

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Is it Greater than it Should Be?

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

The United States has historically relied on specialist physicians more heavily than other developed countries, and some health policy experts have long recommended expanding the share and role of primary care physicians (PCPs) as a way to deliver more cost-effective care. During the 1990s, several converging forces -- the growth of managed care, evolving practice arrangements, and advances in medical technology -- were broadening the range of conditions that PCPs were expected to manage without specialist referral. This Issue Brief presents findings, originally published in the New England Journal of Medicine, showing that many physicians believed the scope of primary care was expanding. Nearly one in four PCPs reported that what they were expected to handle without a referral exceeded what they considered appropriate.

The Expanding Scope of Primary Care

Interest in strengthening the role of primary care had deep roots in health policy. Proponents argued that greater reliance on PCPs would reduce unnecessary or inappropriate use of expensive specialty services and lead to better, more cost-effective care overall. Managed care plans and physician organizations developed a range of mechanisms to channel more patient care through PCPs, including gatekeeping requirements, practice profiling, and financial incentives such as capitation. These tools could directly affect how complex a case a PCP was expected to manage before referring to a specialist.

At the same time, advances in diagnostic and treatment capabilities were independently expanding what PCPs could do. New tests, medications, and office procedures allowed primary care doctors to address conditions that would previously have required specialist involvement.

The concern was whether these forces were pushing PCPs beyond what was appropriate. Patients and physicians raised worries that managed care techniques designed to control specialty referrals might inappropriately restrict access to specialists. Many states responded with legislation allowing patients to designate a specialist as their PCP or to see certain specialists repeatedly after an initial referral. Congress was also considering these measures, along with limits on financial incentives that could discourage specialist use. Some managed care plans had independently developed open-access products giving patients more autonomy in seeking specialty care.

Physicians Report a Shift in Roles

The Community Tracking Study Physician Survey, conducted in 1996-1997 across 60 communities, provided the first systematic data on changes in PCPs' scope of care and physicians' assessment of whether those changes were appropriate.

Thirty percent of PCPs and 50 percent of specialists reported that the scope of care provided by PCPs had expanded over the preceding two years. When asked about the appropriateness of current expectations, nearly three in four PCPs said their scope of care was "about right." However, nearly one in four said the complexity or severity of conditions they were expected to manage without a referral was greater than it should be.

Specialists saw the issue differently. Thirty-eight percent of specialists reported that the complexity or severity of patients' conditions at the time of referral from a PCP was greater than it should be -- suggesting that patients were arriving at specialists' offices sicker or with more advanced conditions than they should have been. Fifty-three percent said the severity at referral was about right, and 9 percent said it was less than it should be.

What Drove Physician Concerns?

The study identified several factors associated with PCPs' concerns about the appropriateness of their expanding scope, after controlling for physician characteristics, market conditions, and other variables.

The single strongest predictor was whether a PCP reported that their scope of care had actually expanded in the prior two years. Those who perceived an increase were more than twice as likely to express concern about the appropriateness of what was expected of them compared with those who did not report an increase.

Specific managed care mechanisms were associated with greater concern. PCPs in practices that received some capitated revenue were more likely to say their scope was excessive than those with no capitation. Participation in gatekeeping arrangements also correlated with concern, and the relationship strengthened with the extent of gatekeeping involvement. However, the study did not find that total managed care revenue broadly defined -- including PPO revenue -- was itself a predictor of concern.

Practice size also mattered. PCPs in smaller practices were generally more likely to express discomfort with the scope expected of them than those in larger groups. Larger practices offered more opportunities for informal colleague consultations -- the "curbside consult" -- which appeared to help physicians feel more comfortable handling a broader range of conditions. Family and general practice physicians were less likely to express concern than general internists and pediatricians.

Implications for Policy and Practice

The association between gatekeeping, capitation, and PCP concern suggested that these managed care mechanisms -- while designed to curb unnecessary specialty referrals -- could be shifting the boundary between primary and specialty care in ways that left some PCPs uncomfortable. At the same time, managed care without gatekeeping or capitation did not appear to raise the same level of concern, pointing to these specific tools rather than managed care in general as the issue.

The finding that larger practices provided a buffer against concern had practical significance. As the trend toward larger group practices continued, it could naturally mitigate some of the discomfort that came with an expanding scope of care. The availability of colleagues to consult informally appeared to play an important role in how confident PCPs felt about handling more complex cases.

Concern about scope of care was not limited to PCPs in high-managed-care environments. Even among the groups with the lowest likelihood of concern -- those who had not perceived an increase in scope, had no gatekeeping responsibility, or practiced in large groups -- about 16 percent still expressed concern. This suggested that broader factors, including the growing complexity of medicine itself, contributed to the discomfort. Some of the concern may also have been transitional, reflecting the adjustment period as PCPs adapted to an evolving role.

The study could not determine whether physicians' concerns about scope translated into actual clinical quality problems -- answering that question would require medical record reviews and direct quality measures. But the fact that a substantial minority of both PCPs and specialists expressed concern about the boundary between primary and specialty care raised the possibility that quality was being affected. This reinforced the importance of directly measuring clinical quality and monitoring the appropriateness of patients' access to specialist services.

For policy makers, the findings pointed toward several possible responses: more intensive quality monitoring focused on access to specialty care, training and continuing education programs designed to prepare PCPs for an expanding role, and careful attention to how managed care tools like gatekeeping and capitation were implemented to ensure they did not push the PCP-specialist boundary beyond what was clinically appropriate.

Data Sources

This Issue Brief drew on data from the Community Tracking Study Physician Survey, a nationally representative telephone survey of nonfederal, patient-care physicians conducted in 60 communities between July 1996 and August 1997. PCPs were oversampled, and the survey captured observations from more than 12,000 physicians with a 65 percent response rate. Data in the multivariate analysis controlled for market conditions, years in practice, and other physician characteristics.

Sources and Further Reading

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, published in the New England Journal of Medicine.

Related HSC publications: "How Physician Organizations Are Responding to Managed Care," Issue Brief No. 20, May 1999; "Access to Specialists," Data Bulletin No. 02, Fall 1997.