It Takes a Balanced Health Care System to Get It Right

Two US state-based reports in this issue of JFP focus attention on relationships between primary care physicians and those in other specialties. From California¹ the results of a mailed survey show that specialists’ attitudes were mixed regarding primary care physicians as gatekeepers. Approximately half of the responding specialists viewed the involvement of a primary care gatekeeper as a hindrance to their patient care. These attitudes differed significantly, however, depending on the specialists’ practice setting and payment plan. Those physicians who were paid a salary or paid by capitation and those working in larger, more organized practice settings had more favorable views toward the role of gatekeeper. Although this study confirms associations, not causes, it emphasizes the value that medical specialists placed on the gatekeeping role in health care systems structured to control costs. These findings show that specialists’ attitudes toward primary care are sensitive to their perception of risk for loss of referrals and income. This is consistent with anecdotal experiences of large group practices in which responsibility for a condition is viewed as belonging squarely in primary care if a specialty is capitated, but that the condition probably needs a referral if the specialty is paid on a fee-for-service basis.

From Florida,² an ecologic analysis shows another reason that we should care about the relationships between primary care and other specialties. Assigning patients with colorectal cancer to their county of residence, this careful analysis found that the incidence and mortality of colorectal cancer decreased in Florida counties that had a greater number of primary care physicians (primary care defined as family practice, general practice, obstetrics/gynecology, or general internal medicine). Although this association at a population level may be different at the level of individual patients, the findings are consistent with a large body of established literature about the value of primary care^3,4 and its effect on important things like mortality.^5-7 The ability of primary care clinicians to provide better screening and earlier diagnoses may explain the association. Strikingly, overall physician supply was not a significant predictor of any of the outcomes examined. The authors rightly conclude that their findings suggest that a balanced work force is probably necessary to achieve the best outcomes.

The call for a balanced approach to the organization of health care services is neither new⁸ or outdated.⁹ Given that the United States has many physicians and spends more money than any other country on health care (more $1.3 trillion; almost $300 billion for physician services in 2000)¹⁰ for mediocre results (37th in overall health system performance according to the World Health Organization’s ranking of nations),¹¹ it makes sense to look at the mix of physicians and the way they work together—or do not work together—for opportunities to enhance performance.

As of the middle of 2000, the proportion of physicians in primary care (defined here as family practice, general practice, general internal medicine, and general pediatrics) ranged from lows of 27.8% (District of Columbia) and 31.6% (Connecticut) to highs of 42.9% (Alaska) and 41.7% (Iowa), with Florida nestled in the middle at 33.5%.¹² This relatively small proportion of primary care physicians is different from other countries, such as the Australia and the United Kingdom, where approximately 44% and 63% of physicians, respectively, are in primary care.¹³ This is widely believed to be a contributing factor to the relatively poor performance of the health care system of the United States. The paper by Roetzheim and colleagues² should direct attention to the deployment of a skilled workforce to achieve the primary care function because it matters to people.

Fretting over money should be expected when so much of it is at stake. In 1997 United States primary care physicians reported average annual incomes after expenses, but before taxes, of $156,061 when working an average of 45.4 hours per week.¹⁴ This compared with $229,447 for physicians in other specialties providing direct patient care and working an average of 47.6 hours per week. Thus, the income of primary care physicians was approximately 68% as much as other physicians directly caring for patients, while working approximately 95% as many hours. California physicians reported a similar pattern, but net incomes for both primary care and other specialties were approximately 14% less in California than in the United States overall, with a slightly shorter work week in California for both groups.

These statistics are not news, of course, but they provide a context for the views of California physicians reported by Peña-Dolhun and coworkers.¹ They suggest how there could be feelings of inequity among primary care physicians and feelings of threat among some hard-working specialists who trained longer than most physicians doing primary care. These income differentials offer an explanation for why students might find primary care practice relatively unrewarding financially. They also show why the public lacks sympathy for physicians squabbling about money.