Unlocking Specialists’ Attitudes Toward Primary Care Gatekeepers

A well-functioning health system requires effective cooperation between primary care and specialist physicians. Tensions between these types of physicians seem to be increasing because of managed care plans, many of which rely on primary care physician gatekeepers to authorize visits to specialists, interrupting the direct access to specialists that many insured Americans expect. Researchers have investigated how gatekeeper policies are affecting primary care physicians and patients.^1-11 However, little research has explored the attitudes of specialist physicians toward the changing role of their primary care counterparts.^12,13 Some specialists appear to be troubled by gatekeeper policies, viewing primary care physicians as their competitors rather than their colleagues.^14-17

Professional organizations representing specialists have advocated for “direct access” legislation that would require health plans to permit patients to visit a specialist without first contacting a primary care physician. These groups have promoted this type of legislation as something that is important for ensuring quality of care. However, more than the patient’s welfare may be at stake in this policy debate. Gatekeeper policies that potentially reduce use of specialist services may be reducing specialist income, particularly when those physicians are paid on a fee-for-service basis.

We surveyed specialist physicians in California to investigate their attitudes toward primary care physicians acting in a gatekeeper role. We explored whether specialist attitudes differed depending on the setting in which the physician practiced and how the physician was paid. We hypothesized that those specialists compensated mainly on a fee-for-service basis would be more financially threatened by gatekeeper policies and would therefore have less favorable attitudes toward primary care physicians in this role. We also hypothesized that specialists working in larger group practice settings would have more collegial relationships with primary care associates that would promote more favorable attitudes.

Methods

In 1998 we mailed self-administered questionnaires to specialist physicians practicing in the 13 largest urban counties in California (Alameda, Contra Costa, Fresno, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Sacramento, San Francisco, San Mateo, Santa Clara, and Solano). The study counties contained 79% of California’s practicing specialist physicians and 79% of the state’s population. The physicians were identified from the American Medical Association (AMA) physician masterfile. The masterfile contains continuously updated information on all US allopathic physicians and many osteopathic physicians, including those who are not AMA members. To be eligible for the survey, physicians had to be listed as providing direct patient care, not in training, and not employed by the federal government.

Specialists were sampled who listed their primary specialty as cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, or orthopedics. These specialties were chosen to provide a broad spectrum of both surgical and medical office-based subspecialties, and to represent most of the largest non–primary care office-based specialties in California. Physicians were selected using a probability sample stratified by specialty (250 physicians in each specialty) and physician race/ethnicity (nonwhite physicians were oversampled). To develop a valid set of questions, we first pilot-tested our questionnaire on a group of 10 specialty physicians. The questionnaire included items on physician demographics, practice setting, number of physicians in the practice, and modes of payment. For analyzing payment modes, physicians were first categorized as salaried or nonsalaried; those that were nonsalaried were asked to indicate the percentage of their practice income derived from fee-for-service and capitated payment.

The questionnaire included a series of items about specialists’ attitudes toward primary care physicians in the gatekeeper role. The specialists were asked to respond to each of the following statements with “strongly agree,” “agree,” disagree,” or “strongly disagree”: “The involvement of a primary care gatekeeper in the care of the patients I see: (1) undermines my relationships with patients; (2) makes it more difficult to order expensive tests or procedures; (3) decreases freedom to make clinical decisions; (4) increases the likelihood that patients will receive preventive care; and (5) improves the coordination of patient care.” For simple descriptive analysis of the individual gatekeeper items, responses were collapsed into dichotomous categories of “agree” or “disagree.”

In addition to analyzing individual attitude items, we created a summary Attitude Toward Gatekeepers scale. To create this scale, individual attitude items worded in a negative direction (eg, the gatekeeper undermines my relationship with patients) were scored so that a score of 4 indicated maximal disagreement. Items worded in a positive direction (eg, the gatekeeper increases the likelihood that patients will receive preventive care) were scored with 4 representing maximal agreement. The summary attitudes toward gatekeeper score was then computed by calculating the mean of the 5 separate gatekeeper items for each physician. This summary scale had a range of 1 to 4, with 2.5 indicating a neutral summary attitude. The Cronbach a for the summary scale was 0.75, indicating acceptable scale properties.

Analysis

Mean scores for the summary Attitude Toward Gatekeeper scale were compared according to physician demographics and practice characteristics using t tests and analysis of variance. For these unadjusted analyses, the physician payment variable was classified into 3 mutually exclusive categories: salaried, capitated for 40% or more of practice income, or fee-for-service payment accounting for 61% or more of practice income. We based the 40% threshold for capitated income on the assumption that this degree of capitation would be sufficient to change the underlying financial incentive experienced by physicians in regard to referral visit volume.

We also performed least squares regression analysis to investigate the independent association of physician and practice variables with the summary Attitude Toward Gatekeeper scale. All physician demographic and practice variables were entered into the regression equation, regardless of their significance on unadjusted analysis. For the regression model, payment mode was categorized in a manner different from that used for the unadjusted analyses. First, a dummy variable was created indicating whether the physician was salaried or nonsalaried. A second variable was included in the model indicating the percentage of practice income attributable to capitated payment. For salaried physicians, the value of this continuous capitation income variable was set at 0. This approach results in an interpretation of the coefficient for the salaried variable indicating the change in gatekeeper attitude scale score for salaried physicians relative to nonsalaried physicians with only fee-for-service payment.

Data were also analyzed after being weighted to account for the oversampling of nonwhite physicians and for the differences in sampling proportions among the different specialties relative to the overall population of physicians in each specialty in the study counties. The results were almost identical when we used the weighted and unweighted data; we therefore present results only from the more simple unweighted analyses.

The University of California, San Francisco, Committee on Human Research reviewed and approved the study protocol.

Results

Of the initial sample of 1750 physicians, 258 were subsequently determined to be ineligible, primarily due to death, retirement, or moving out of the study counties. Completed questionnaires were obtained from 979 of the 1492 eligible specialist physicians (66%). Sixteen of those responding worked in public clinics or other practice settings, such as schools or jails. Given the uniqueness of their practice settings and the small number of physicians there, we excluded these 16 and analyzed the responses of the remaining 963.

The characteristics of the physician respondents are shown in Table 1. Most (73%) were in solo or small office-based group practices of 2 to 10 physicians. Most had fee-for-service payment as their dominant payment method. One fourth were paid on a salaried basis, and 16% had at least 40% of their practice income paid by capitation.

Attitudes toward primary care physicians in the gatekeeper role were mixed Table 2. Almost half (44%) agreed that the gatekeeper undermines a specialist’s relationship with patients. Fifty-six percent agreed that the gatekeeper makes it more difficult to order expensive tests or procedures, and two thirds agreed that the gatekeeper decreases the freedom of the specialist to make clinical decisions. In response to the attitude items positing beneficial effects of a primary care gatekeeper arrangement, 40% agreed that the primary gatekeeper improves coordination of care, and half agreed that the gatekeeper increases the likelihood that the patient will receive preventive care. When all 5 questions were combined into a single summary scale, the general attitude of the specialist physicians toward primary care gatekeepers was essentially neutral, with a mean among all specialists of 2.4 (standard deviation=0.69) on a scale of 1 to 4.

On unadjusted analyses, practice setting and payment method were the strongest predictors of the summary Attitude Toward Gatekeeper score Table 3. Specialists in solo practice exhibited the most negative attitudes. The attitudes of specialists in small (2-10 physicians) and medium-sized (11-50) group practice settings were only slightly more favorable. Attitudes were much more positive among specialists working in large practice settings (>50 physicians) and especially among physicians working in group-model health maintenance organizations (P <.001) for overall difference across practice settings. Method of payment was also significantly associated with specialist attitudes (P <.001) for differences across payment categories. 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.

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.

Our study has several policy implications. Our results indicate that specialists vary in their attitudes toward the gatekeeping role of primary care physicians and that negative attitudes are not necessarily an immutable characteristic of being a specialist. Attitudes appear to be shaped at least in part by the specialists’ financial interest that may be threatened by restrictions on referrals and by the system in which they practice. Policies that promote alternatives to fee-for-service payment and shift specialists away from solo practice toward larger, organized group practice settings may also encourage them to adopt more positive attitudes about the role of primary care physicians as coordinators of care. Integrated work environments may generate a common sense of purpose, stemming in part from physical proximity to facilitate communication and cooperation.

Limitations

Several limitations of our study are worth noting. Our study was limited to physicians in California. Although California has one of the most competitive managed care markets in the United States and may exemplify trends occurring in other states with active managed care markets, results may not necessarily be generalizable to physicians working in other states. Our main study variable—attitudes toward primary care gatekeepers—is a subjective measure. The wording of our main study question specifically highlighted primary care physicians in a gatekeeper role. The response to this question is therefore not necessarily indicative of the attitudes of specialists toward primary care physicians in general. Interpretation of the word “gatekeeper” was left up to the respondent. Finally, as in all observational studies, causal inferences must be made with caution. We detected strong associations between payment method and practice setting and specialists’ attitudes toward gatekeepers. Although it is plausible that payment incentives and practice environment influence specialist attitudes, it is also possible that specialists who have different underlying values are attracted to different types of practice settings and payment arrangements. For example, salaried group-model HMOs may attract specialists who already have relatively favorable attitudes toward primary care gatekeeping, rather than (or in addition to) that culture promoting a more favorable attitude. Solo practice, in contrast, may attract physicians who are more independent and predisposed to perceive the gatekeeper role as adversarial.

Conclusions

In the US health care system gatekeeping remains controversial. Specialist ambivalence toward gatekeeper models may undermine the legitimacy of a more primary care–focused system. 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.¹⁸ Models of care that promote integration and coordination by primary care physicians without emphasizing a restricting role may decrease tensions among physicians. 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.¹⁹ 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.

· Acknowledgments ·

This work was supported by the Bureau of Health Professions, HRSA (Grant 5 U76 MB 10001). The authors thank Dennis Keane, MPH, and Deborah Jaffe for their assistance with survey administration; Art Munger for assistance with manuscript preparation; Norman Hearst, MD, MPH, for his comments on early drafts; and the physicians who participated in the study.

A well-functioning health system requires effective cooperation between primary care and specialist physicians. Tensions between these types of physicians seem to be increasing because of managed care plans, many of which rely on primary care physician gatekeepers to authorize visits to specialists, interrupting the direct access to specialists that many insured Americans expect. Researchers have investigated how gatekeeper policies are affecting primary care physicians and patients.^1-11 However, little research has explored the attitudes of specialist physicians toward the changing role of their primary care counterparts.^12,13 Some specialists appear to be troubled by gatekeeper policies, viewing primary care physicians as their competitors rather than their colleagues.^14-17

Professional organizations representing specialists have advocated for “direct access” legislation that would require health plans to permit patients to visit a specialist without first contacting a primary care physician. These groups have promoted this type of legislation as something that is important for ensuring quality of care. However, more than the patient’s welfare may be at stake in this policy debate. Gatekeeper policies that potentially reduce use of specialist services may be reducing specialist income, particularly when those physicians are paid on a fee-for-service basis.

We surveyed specialist physicians in California to investigate their attitudes toward primary care physicians acting in a gatekeeper role. We explored whether specialist attitudes differed depending on the setting in which the physician practiced and how the physician was paid. We hypothesized that those specialists compensated mainly on a fee-for-service basis would be more financially threatened by gatekeeper policies and would therefore have less favorable attitudes toward primary care physicians in this role. We also hypothesized that specialists working in larger group practice settings would have more collegial relationships with primary care associates that would promote more favorable attitudes.

Methods

In 1998 we mailed self-administered questionnaires to specialist physicians practicing in the 13 largest urban counties in California (Alameda, Contra Costa, Fresno, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Sacramento, San Francisco, San Mateo, Santa Clara, and Solano). The study counties contained 79% of California’s practicing specialist physicians and 79% of the state’s population. The physicians were identified from the American Medical Association (AMA) physician masterfile. The masterfile contains continuously updated information on all US allopathic physicians and many osteopathic physicians, including those who are not AMA members. To be eligible for the survey, physicians had to be listed as providing direct patient care, not in training, and not employed by the federal government.

Specialists were sampled who listed their primary specialty as cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, or orthopedics. These specialties were chosen to provide a broad spectrum of both surgical and medical office-based subspecialties, and to represent most of the largest non–primary care office-based specialties in California. Physicians were selected using a probability sample stratified by specialty (250 physicians in each specialty) and physician race/ethnicity (nonwhite physicians were oversampled). To develop a valid set of questions, we first pilot-tested our questionnaire on a group of 10 specialty physicians. The questionnaire included items on physician demographics, practice setting, number of physicians in the practice, and modes of payment. For analyzing payment modes, physicians were first categorized as salaried or nonsalaried; those that were nonsalaried were asked to indicate the percentage of their practice income derived from fee-for-service and capitated payment.

The questionnaire included a series of items about specialists’ attitudes toward primary care physicians in the gatekeeper role. The specialists were asked to respond to each of the following statements with “strongly agree,” “agree,” disagree,” or “strongly disagree”: “The involvement of a primary care gatekeeper in the care of the patients I see: (1) undermines my relationships with patients; (2) makes it more difficult to order expensive tests or procedures; (3) decreases freedom to make clinical decisions; (4) increases the likelihood that patients will receive preventive care; and (5) improves the coordination of patient care.” For simple descriptive analysis of the individual gatekeeper items, responses were collapsed into dichotomous categories of “agree” or “disagree.”

In addition to analyzing individual attitude items, we created a summary Attitude Toward Gatekeepers scale. To create this scale, individual attitude items worded in a negative direction (eg, the gatekeeper undermines my relationship with patients) were scored so that a score of 4 indicated maximal disagreement. Items worded in a positive direction (eg, the gatekeeper increases the likelihood that patients will receive preventive care) were scored with 4 representing maximal agreement. The summary attitudes toward gatekeeper score was then computed by calculating the mean of the 5 separate gatekeeper items for each physician. This summary scale had a range of 1 to 4, with 2.5 indicating a neutral summary attitude. The Cronbach a for the summary scale was 0.75, indicating acceptable scale properties.

Analysis

Mean scores for the summary Attitude Toward Gatekeeper scale were compared according to physician demographics and practice characteristics using t tests and analysis of variance. For these unadjusted analyses, the physician payment variable was classified into 3 mutually exclusive categories: salaried, capitated for 40% or more of practice income, or fee-for-service payment accounting for 61% or more of practice income. We based the 40% threshold for capitated income on the assumption that this degree of capitation would be sufficient to change the underlying financial incentive experienced by physicians in regard to referral visit volume.

We also performed least squares regression analysis to investigate the independent association of physician and practice variables with the summary Attitude Toward Gatekeeper scale. All physician demographic and practice variables were entered into the regression equation, regardless of their significance on unadjusted analysis. For the regression model, payment mode was categorized in a manner different from that used for the unadjusted analyses. First, a dummy variable was created indicating whether the physician was salaried or nonsalaried. A second variable was included in the model indicating the percentage of practice income attributable to capitated payment. For salaried physicians, the value of this continuous capitation income variable was set at 0. This approach results in an interpretation of the coefficient for the salaried variable indicating the change in gatekeeper attitude scale score for salaried physicians relative to nonsalaried physicians with only fee-for-service payment.

Data were also analyzed after being weighted to account for the oversampling of nonwhite physicians and for the differences in sampling proportions among the different specialties relative to the overall population of physicians in each specialty in the study counties. The results were almost identical when we used the weighted and unweighted data; we therefore present results only from the more simple unweighted analyses.

The University of California, San Francisco, Committee on Human Research reviewed and approved the study protocol.

Results

Of the initial sample of 1750 physicians, 258 were subsequently determined to be ineligible, primarily due to death, retirement, or moving out of the study counties. Completed questionnaires were obtained from 979 of the 1492 eligible specialist physicians (66%). Sixteen of those responding worked in public clinics or other practice settings, such as schools or jails. Given the uniqueness of their practice settings and the small number of physicians there, we excluded these 16 and analyzed the responses of the remaining 963.

The characteristics of the physician respondents are shown in Table 1. Most (73%) were in solo or small office-based group practices of 2 to 10 physicians. Most had fee-for-service payment as their dominant payment method. One fourth were paid on a salaried basis, and 16% had at least 40% of their practice income paid by capitation.

Attitudes toward primary care physicians in the gatekeeper role were mixed Table 2. Almost half (44%) agreed that the gatekeeper undermines a specialist’s relationship with patients. Fifty-six percent agreed that the gatekeeper makes it more difficult to order expensive tests or procedures, and two thirds agreed that the gatekeeper decreases the freedom of the specialist to make clinical decisions. In response to the attitude items positing beneficial effects of a primary care gatekeeper arrangement, 40% agreed that the primary gatekeeper improves coordination of care, and half agreed that the gatekeeper increases the likelihood that the patient will receive preventive care. When all 5 questions were combined into a single summary scale, the general attitude of the specialist physicians toward primary care gatekeepers was essentially neutral, with a mean among all specialists of 2.4 (standard deviation=0.69) on a scale of 1 to 4.

On unadjusted analyses, practice setting and payment method were the strongest predictors of the summary Attitude Toward Gatekeeper score Table 3. Specialists in solo practice exhibited the most negative attitudes. The attitudes of specialists in small (2-10 physicians) and medium-sized (11-50) group practice settings were only slightly more favorable. Attitudes were much more positive among specialists working in large practice settings (>50 physicians) and especially among physicians working in group-model health maintenance organizations (P <.001) for overall difference across practice settings. Method of payment was also significantly associated with specialist attitudes (P <.001) for differences across payment categories. 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.

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.

Our study has several policy implications. Our results indicate that specialists vary in their attitudes toward the gatekeeping role of primary care physicians and that negative attitudes are not necessarily an immutable characteristic of being a specialist. Attitudes appear to be shaped at least in part by the specialists’ financial interest that may be threatened by restrictions on referrals and by the system in which they practice. Policies that promote alternatives to fee-for-service payment and shift specialists away from solo practice toward larger, organized group practice settings may also encourage them to adopt more positive attitudes about the role of primary care physicians as coordinators of care. Integrated work environments may generate a common sense of purpose, stemming in part from physical proximity to facilitate communication and cooperation.

Limitations

Several limitations of our study are worth noting. Our study was limited to physicians in California. Although California has one of the most competitive managed care markets in the United States and may exemplify trends occurring in other states with active managed care markets, results may not necessarily be generalizable to physicians working in other states. Our main study variable—attitudes toward primary care gatekeepers—is a subjective measure. The wording of our main study question specifically highlighted primary care physicians in a gatekeeper role. The response to this question is therefore not necessarily indicative of the attitudes of specialists toward primary care physicians in general. Interpretation of the word “gatekeeper” was left up to the respondent. Finally, as in all observational studies, causal inferences must be made with caution. We detected strong associations between payment method and practice setting and specialists’ attitudes toward gatekeepers. Although it is plausible that payment incentives and practice environment influence specialist attitudes, it is also possible that specialists who have different underlying values are attracted to different types of practice settings and payment arrangements. For example, salaried group-model HMOs may attract specialists who already have relatively favorable attitudes toward primary care gatekeeping, rather than (or in addition to) that culture promoting a more favorable attitude. Solo practice, in contrast, may attract physicians who are more independent and predisposed to perceive the gatekeeper role as adversarial.

Conclusions

In the US health care system gatekeeping remains controversial. Specialist ambivalence toward gatekeeper models may undermine the legitimacy of a more primary care–focused system. 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.¹⁸ Models of care that promote integration and coordination by primary care physicians without emphasizing a restricting role may decrease tensions among physicians. 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.¹⁹ 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.

· Acknowledgments ·

This work was supported by the Bureau of Health Professions, HRSA (Grant 5 U76 MB 10001). The authors thank Dennis Keane, MPH, and Deborah Jaffe for their assistance with survey administration; Art Munger for assistance with manuscript preparation; Norman Hearst, MD, MPH, for his comments on early drafts; and the physicians who participated in the study.

A well-functioning health system requires effective cooperation between primary care and specialist physicians. Tensions between these types of physicians seem to be increasing because of managed care plans, many of which rely on primary care physician gatekeepers to authorize visits to specialists, interrupting the direct access to specialists that many insured Americans expect. Researchers have investigated how gatekeeper policies are affecting primary care physicians and patients.^1-11 However, little research has explored the attitudes of specialist physicians toward the changing role of their primary care counterparts.^12,13 Some specialists appear to be troubled by gatekeeper policies, viewing primary care physicians as their competitors rather than their colleagues.^14-17

Professional organizations representing specialists have advocated for “direct access” legislation that would require health plans to permit patients to visit a specialist without first contacting a primary care physician. These groups have promoted this type of legislation as something that is important for ensuring quality of care. However, more than the patient’s welfare may be at stake in this policy debate. Gatekeeper policies that potentially reduce use of specialist services may be reducing specialist income, particularly when those physicians are paid on a fee-for-service basis.

We surveyed specialist physicians in California to investigate their attitudes toward primary care physicians acting in a gatekeeper role. We explored whether specialist attitudes differed depending on the setting in which the physician practiced and how the physician was paid. We hypothesized that those specialists compensated mainly on a fee-for-service basis would be more financially threatened by gatekeeper policies and would therefore have less favorable attitudes toward primary care physicians in this role. We also hypothesized that specialists working in larger group practice settings would have more collegial relationships with primary care associates that would promote more favorable attitudes.

Methods

In 1998 we mailed self-administered questionnaires to specialist physicians practicing in the 13 largest urban counties in California (Alameda, Contra Costa, Fresno, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Sacramento, San Francisco, San Mateo, Santa Clara, and Solano). The study counties contained 79% of California’s practicing specialist physicians and 79% of the state’s population. The physicians were identified from the American Medical Association (AMA) physician masterfile. The masterfile contains continuously updated information on all US allopathic physicians and many osteopathic physicians, including those who are not AMA members. To be eligible for the survey, physicians had to be listed as providing direct patient care, not in training, and not employed by the federal government.

Specialists were sampled who listed their primary specialty as cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, or orthopedics. These specialties were chosen to provide a broad spectrum of both surgical and medical office-based subspecialties, and to represent most of the largest non–primary care office-based specialties in California. Physicians were selected using a probability sample stratified by specialty (250 physicians in each specialty) and physician race/ethnicity (nonwhite physicians were oversampled). To develop a valid set of questions, we first pilot-tested our questionnaire on a group of 10 specialty physicians. The questionnaire included items on physician demographics, practice setting, number of physicians in the practice, and modes of payment. For analyzing payment modes, physicians were first categorized as salaried or nonsalaried; those that were nonsalaried were asked to indicate the percentage of their practice income derived from fee-for-service and capitated payment.

The questionnaire included a series of items about specialists’ attitudes toward primary care physicians in the gatekeeper role. The specialists were asked to respond to each of the following statements with “strongly agree,” “agree,” disagree,” or “strongly disagree”: “The involvement of a primary care gatekeeper in the care of the patients I see: (1) undermines my relationships with patients; (2) makes it more difficult to order expensive tests or procedures; (3) decreases freedom to make clinical decisions; (4) increases the likelihood that patients will receive preventive care; and (5) improves the coordination of patient care.” For simple descriptive analysis of the individual gatekeeper items, responses were collapsed into dichotomous categories of “agree” or “disagree.”

In addition to analyzing individual attitude items, we created a summary Attitude Toward Gatekeepers scale. To create this scale, individual attitude items worded in a negative direction (eg, the gatekeeper undermines my relationship with patients) were scored so that a score of 4 indicated maximal disagreement. Items worded in a positive direction (eg, the gatekeeper increases the likelihood that patients will receive preventive care) were scored with 4 representing maximal agreement. The summary attitudes toward gatekeeper score was then computed by calculating the mean of the 5 separate gatekeeper items for each physician. This summary scale had a range of 1 to 4, with 2.5 indicating a neutral summary attitude. The Cronbach a for the summary scale was 0.75, indicating acceptable scale properties.

Analysis

Mean scores for the summary Attitude Toward Gatekeeper scale were compared according to physician demographics and practice characteristics using t tests and analysis of variance. For these unadjusted analyses, the physician payment variable was classified into 3 mutually exclusive categories: salaried, capitated for 40% or more of practice income, or fee-for-service payment accounting for 61% or more of practice income. We based the 40% threshold for capitated income on the assumption that this degree of capitation would be sufficient to change the underlying financial incentive experienced by physicians in regard to referral visit volume.

We also performed least squares regression analysis to investigate the independent association of physician and practice variables with the summary Attitude Toward Gatekeeper scale. All physician demographic and practice variables were entered into the regression equation, regardless of their significance on unadjusted analysis. For the regression model, payment mode was categorized in a manner different from that used for the unadjusted analyses. First, a dummy variable was created indicating whether the physician was salaried or nonsalaried. A second variable was included in the model indicating the percentage of practice income attributable to capitated payment. For salaried physicians, the value of this continuous capitation income variable was set at 0. This approach results in an interpretation of the coefficient for the salaried variable indicating the change in gatekeeper attitude scale score for salaried physicians relative to nonsalaried physicians with only fee-for-service payment.

Data were also analyzed after being weighted to account for the oversampling of nonwhite physicians and for the differences in sampling proportions among the different specialties relative to the overall population of physicians in each specialty in the study counties. The results were almost identical when we used the weighted and unweighted data; we therefore present results only from the more simple unweighted analyses.

The University of California, San Francisco, Committee on Human Research reviewed and approved the study protocol.

Results

Of the initial sample of 1750 physicians, 258 were subsequently determined to be ineligible, primarily due to death, retirement, or moving out of the study counties. Completed questionnaires were obtained from 979 of the 1492 eligible specialist physicians (66%). Sixteen of those responding worked in public clinics or other practice settings, such as schools or jails. Given the uniqueness of their practice settings and the small number of physicians there, we excluded these 16 and analyzed the responses of the remaining 963.

The characteristics of the physician respondents are shown in Table 1. Most (73%) were in solo or small office-based group practices of 2 to 10 physicians. Most had fee-for-service payment as their dominant payment method. One fourth were paid on a salaried basis, and 16% had at least 40% of their practice income paid by capitation.

Attitudes toward primary care physicians in the gatekeeper role were mixed Table 2. Almost half (44%) agreed that the gatekeeper undermines a specialist’s relationship with patients. Fifty-six percent agreed that the gatekeeper makes it more difficult to order expensive tests or procedures, and two thirds agreed that the gatekeeper decreases the freedom of the specialist to make clinical decisions. In response to the attitude items positing beneficial effects of a primary care gatekeeper arrangement, 40% agreed that the primary gatekeeper improves coordination of care, and half agreed that the gatekeeper increases the likelihood that the patient will receive preventive care. When all 5 questions were combined into a single summary scale, the general attitude of the specialist physicians toward primary care gatekeepers was essentially neutral, with a mean among all specialists of 2.4 (standard deviation=0.69) on a scale of 1 to 4.

On unadjusted analyses, practice setting and payment method were the strongest predictors of the summary Attitude Toward Gatekeeper score Table 3. Specialists in solo practice exhibited the most negative attitudes. The attitudes of specialists in small (2-10 physicians) and medium-sized (11-50) group practice settings were only slightly more favorable. Attitudes were much more positive among specialists working in large practice settings (>50 physicians) and especially among physicians working in group-model health maintenance organizations (P <.001) for overall difference across practice settings. Method of payment was also significantly associated with specialist attitudes (P <.001) for differences across payment categories. 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.

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.

Our study has several policy implications. Our results indicate that specialists vary in their attitudes toward the gatekeeping role of primary care physicians and that negative attitudes are not necessarily an immutable characteristic of being a specialist. Attitudes appear to be shaped at least in part by the specialists’ financial interest that may be threatened by restrictions on referrals and by the system in which they practice. Policies that promote alternatives to fee-for-service payment and shift specialists away from solo practice toward larger, organized group practice settings may also encourage them to adopt more positive attitudes about the role of primary care physicians as coordinators of care. Integrated work environments may generate a common sense of purpose, stemming in part from physical proximity to facilitate communication and cooperation.

Limitations

Several limitations of our study are worth noting. Our study was limited to physicians in California. Although California has one of the most competitive managed care markets in the United States and may exemplify trends occurring in other states with active managed care markets, results may not necessarily be generalizable to physicians working in other states. Our main study variable—attitudes toward primary care gatekeepers—is a subjective measure. The wording of our main study question specifically highlighted primary care physicians in a gatekeeper role. The response to this question is therefore not necessarily indicative of the attitudes of specialists toward primary care physicians in general. Interpretation of the word “gatekeeper” was left up to the respondent. Finally, as in all observational studies, causal inferences must be made with caution. We detected strong associations between payment method and practice setting and specialists’ attitudes toward gatekeepers. Although it is plausible that payment incentives and practice environment influence specialist attitudes, it is also possible that specialists who have different underlying values are attracted to different types of practice settings and payment arrangements. For example, salaried group-model HMOs may attract specialists who already have relatively favorable attitudes toward primary care gatekeeping, rather than (or in addition to) that culture promoting a more favorable attitude. Solo practice, in contrast, may attract physicians who are more independent and predisposed to perceive the gatekeeper role as adversarial.

Conclusions

In the US health care system gatekeeping remains controversial. Specialist ambivalence toward gatekeeper models may undermine the legitimacy of a more primary care–focused system. 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.¹⁸ Models of care that promote integration and coordination by primary care physicians without emphasizing a restricting role may decrease tensions among physicians. 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.¹⁹ 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.

· Acknowledgments ·

This work was supported by the Bureau of Health Professions, HRSA (Grant 5 U76 MB 10001). The authors thank Dennis Keane, MPH, and Deborah Jaffe for their assistance with survey administration; Art Munger for assistance with manuscript preparation; Norman Hearst, MD, MPH, for his comments on early drafts; and the physicians who participated in the study.