A recent study at the University of California, San Francisco assessed
specialists’ attitudes toward primary care physicians in the gatekeeper role,
finding the attitudes are influenced by practice settings and by financial
interests that may be threatened by referral restrictions.
“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,” said lead author Eduardo
Pena-Dolhun, MD, UCSF assistant professor in the department of Family and
The study, scheduled for publication in the December 1 issue of The Journal of
Family Practice, is based upon responses from 979 physicians who completed the
survey. Salaried physicians as opposed to specialists in solo practice had a
somewhat more favorable attitude toward gatekeepers as did physicians with a
greater percentage of income derived from capitation.
Practice setting and payment method were among the strongest predictors of
attitudes toward gatekeepers. Specialists in solo practice exhibited the most
negative attitudes, but attitudes were much more positive among specialists
working in large practice settings and especially among physicians working in
health maintenance organizations. Physicians responding came from specialties
including cardiology, endocrinology, gastroenterology, neurology, ophthalmology, orthopedic surgery, and general surgery. Specialists in solo practice exhibited the most negative attitudes. I think that this would be a good place to talk about the financial differences, i.e., fee-for-service v. salary v. captitation.Salaried physicians demonstrated the most favorable attitudes toward gatekeepers and fee-for-service specialists the least favorable attitudes. Those specialists classified as capitated were on average neutral in their views of gatekeepers. Female specialists and those who were
younger also had significantly more favorable gatekeeper attitude scores.. This
last point is true, but we did not emphasize it because of the relatively
smaller numbers in these categories. But I am fine with leaving it in. I
think that we definitely need to say something specifically about the financial
incentives since it is a key issue.
“Although there is widespread support among those surveyed for many of the core
values of primary care, there is also apprehension about policies that insist
that primary care physicians authorize access to specialists, particularly when
primary care physicians or commercial health plans may profit financially by
economizing on specialty services,” said Pena-Dolhun.
The researchers suggested that 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.
“Policies that promote alternatives to fee for service may generate a common
sense of purpose among primary care physicians and specialists,” Pena-Dolhun
said. “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.”
Work on this study was supported by the US Bureau of Health Professions.
Co-authors include Kevin Grumbach, MD, vice-chair of UCSF Family and Community
Medicine; Karen Vranzian, MA, senior statistician, General Internal Medicine at
SFGH Medical Center; Dennis Osmond, PhD, UCSF associate adjunct professor of
Epidemiology at SFGH Medical Center; and Andrew B. Bindman, MD, chief, General
Internal Medicine at SFGH Medical Center.