Unlocking Specialists’ Attitudes Toward Primary Care Gatekeepers
Mean values for the summary gatekeeper attitude score also differed among the different specialty groups. Mean scores ranged from a high of 2.58 among gastroenterologists to a low of 2.15 among ophthalmologists and 2.23 among orthopedists (P <.001). Female specialists and those who were younger also had significantly more favorable mean gatekeeper attitude scores.
In the multivariate regression analysis, practice setting remained strongly predictive of attitudes Table 4. Relative to specialists in solo practice, those in groups of more than 50 physicians had a gatekeeper attitude score nearly half a point more favorable, and specialists in group-model health maintenance organizations (HMOs) had attitude scores nearly a full point more favorable. Relative to nonsalaried physicians, those who were salaried had a somewhat more favorable attitude toward gatekeepers, although the salaried payment variable did not achieve statistical significance (P=.13) in the adjusted analysis. However, the percentage of practice income derived from capitation remained significantly associated with attitudes (P=.002) in the regression analysis. The larger the proportion of income a specialist received from capitation, the more positive the attitudes. Stated inversely, the more a specialist was paid on a fee-for-service basis, the more negative his or her attitudes were toward primary care gatekeepers.
Few other variables included in the regression analysis were statistically significant independent predictors of the gatekeeper score. In the regression model, ophthalmologists remained significantly more negative in their attitudes toward gatekeepers than the other specialists (P=.01) and male physicians remained more negative in their attitudes than women (P=.04); data for these variables not shown). Interestingly, specialist during the previous year was not a significant predictor of attitude. The regression model explained 26% of the variation in the summary gatekeeper score.
Discussion
The role of primary care physicians in the US health care system continues to evolve. Although there is widespread support 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 financially profit by economizing on specialty services.
Research on patient attitudes toward the gatekeeping role of primary care physicians has shown that while they value the comprehensive and coordinating role of primary care physicians, perceptions of referral barriers are one of the strongest predictors of patients giving their primary care physician low trust, confidence, and satisfaction ratings.9 Similarly, studies have indicated that primary care physicians often have ambivalent attitudes about performing gatekeeping functions such as mandatory authorization of all specialist referrals.3,6,11
Our study extends this previous research and demonstrates that specialist physicians also tend to have ambivalent attitudes about the gatekeeping role of primary care physicians. Many specialists in our survey agreed that primary care gatekeepers infringe on specialists’ clinical autonomy and their relationships with patients. However, half also acknowledged that primary care physician gatekeepers increase delivery of preventive services, and 40% agreed that coordination of care is enhanced by the involvement of a primary care gatekeeper.
Overall, specialist attitudes toward primary care physicians acting as gatekeepers were not uniformly negative. Many specialists appear to appreciate the advantages of having a primary care physician to help integrate services.
Our study indicates that specialists’ attitudes toward primary care gatekeepers differ significantly according to how the specialists are paid and the setting in which they practice. Payment methods such as salary and capitation that eliminate or markedly reduce the direct link between volume of referral visits and specialist income appear to promote a more favorable attitude among specialists toward primary care gatekeepers. This finding suggests that the objection of some specialists to a gatekeeping role for primary care physicians may at least in part be due to concerns about possible loss of income under fee-for-service arrangements. It is possible that specialists paid by salary or capitation perceive that a more prominent coordinating role for primary care physicians may be to their professional benefit by reducing inappropriate referrals that bring no additional income to the practice.
Specialists working in larger and more organized practice settings also have more favorable views of primary care gatekeepers. This association between practice setting and attitudes may be partly explained by the fact that physicians in larger groups and group-model HMOs are more likely to be paid on a salaried basis. However, even after adjusting for payment method in regression analysis, practice setting remained predictive of attitudes toward gatekeepers. It is likely that physicians in larger office-based groups and group-model HMOs work in a multispecialty context that promotes a more collaborative and interdependent approach to practice across specialties. This organizational culture may attenuate conflicts between specialty groups about scope of practice, patient allegiances, and the appropriate role of each specialty within the overall system of care.
