Our finding that few OBGs provided broad-spectrum care in 1994 suggests that legislation to increase the use of OBGs as primary care providers could affect the way general medical services are delivered to elderly women. Many of these women may have nongynecologic medical conditions requiring treatment and monitoring. If most OBGs do not routinely provide these services, these women will require referral to medical specialists, which could lead to increasing costs, inconvenience, and fragmentation of care.
We did not expect the findings that rural OBGs provided less nongynecologic care than urban OBGs. Because rural areas are often underserved, we hypothesized that rural OBGs would practice as generalists more often and provide more general medical care. We concluded, therefore, that rural OBGs may be in shorter supply than generalists and that they are filling their practices with visits specific to their specialty. In addition, there may be increased competition among urban OBGs for gynecologic visits, so a larger number of patients are seen for nongynecologic problems.
Limitations
Our study has several limitations. We included only the primary diagnosis for each visit. A patient may have presented with both a gynecologic and non-gynecologic problem, but the OBG may have coded the gynecologic diagnosis as the primary one. In addition, patients presenting for a gynecologic complaint may inquire as an aside about a nongynecologic concern that may have been addressed but not coded. This would underestimate the amount of nongynecologic care provided by OBGs as well as the other studied specialists. However, it is unlikely that every time a woman visits an OBG for an upper respiratory infection, joint pain, or glycohemoglobin monitoring she also has an active gynecologic problem. The methodology we used should identify the portion of OBGs who provided a substantial amount of nongynecologic care.
The scope of OBGs’ practices may have changed since the data were collected. The primary reason for such a change would be the implementation of the primary care requirement during residency. Since that change in training occurred in 1996, however, those residents affected are just now entering the work force. Thus, our study’s data are likely to represent current practice patterns. A follow-up study of the scope of OBGs’ practices in 5 to 10 years will help elucidate the effect of the residency primary care requirement on OBGs’ practices.
The assignment of a diagnosis as in or out of domain is subject to interpretation. ICD-9 codes and diagnosis clusters were reviewed separately by 2 physicians to classify the diagnoses. When there was disagreement, the individuals discussed the diagnosis to reach consensus. If they could not agree, the diagnosis was considered out of domain. For example, the general medical examination was considered out of domain because the exact nature of the visit is unclear; however, the diagnosis may have been used for general gynecologic services provided to women without specific diagnoses, such as annual Papanicolaou tests that would be considered in domain. Since this was a conservative approach, it could overestimate the amount of out of domain care provided.
Only one feature of primary care—the breadth of practice—was addressed in this study. We did not examine a number of other features that also characterize primary care—continuity, coordination, and accessibility—as also described by the Committee on the Future of Primary Care of the IOM.9 In addition, we did not address quality of care.
Since we limited our study to Washington Medicare beneficiaries aged 65 years and older, we cannot comment on the degree to which OBGs may be providing general medical care to patients younger than 65 years. Younger patients may have different relationships with their physicians and present with different medical issues of varying complexity. We also excluded the 15% of Medicare elderly in Washington who in 1994 were enrolled in a managed care health plan. These results cannot be extrapolated to this population, because nearly all health maintenance organizations restrict access to specialists.
The Effect of Legislation
Our findings raise the question of whether legislation that designates OBGs as primary care providers for elderly women would result in an increase in the use of OBGs as providers of care for problems outside the reproductive system or primarily increase access to OBGs’ specialty services. Passage of legislation such as the Patients’ Bill of Rights Act of 1999 may facilitate elderly women’s obtaining primary gynecologic care, yet it may not have the same effect on their receipt of general medical care. A bill like this would allow women of all ages to designate OBGs as their primary care providers, thus allowing unrestricted and direct access to their services. Studies investigating the care received by elderly women enrolled in private health care plans in which they are able to select OBGs as primary care physicians could provide additional useful information. If the Patients’ Bill of Rights Act of 1999 or similar legislation is passed, studies will be needed to assess its effect on the overall medical care received by elderly women.