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8/8/2019 Smile as You Steal My Patient - Primary Care vs Specialists
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www.medscape.com
From Medscape Business of Medicine
Introduction
Thelinebetweenprimarycarephysicians(PCPs)andsubspecialists,neveraclearone,hasblurredevenmore.
ThepercentageofPCPscontinuestoshrink,andpatientseitheraskfororacceptroutinecarefromsubspecialists.Atthesametime,
internists,familypractitioners,andothergeneralists,inanefforttoboostincome,areencroachingonsubspecialists'territorybyofferingavarietyofancillaryservices.
JosephR.Arulandu,MD,aninternistinLaPorte,Indiana,isacaseinpoint."There'snothingmoreirritatingtoprimarycarephysiciansthan
whentheyreferapatienttoasubspecialistwho,afterdoingwhatisasked,proceedstotreatthepatientforroutineissuesthatcanbe
handledbythePCP,"saysArulandu.
"Thisisthebestwayforaspecialisttoloseareferralsource,"hesays."Ontheotherhand,IdoalotofancillaryworkinmyofficethatIused
tosendouttospecialists,andthereforeIneedspecialistslessnowthanIdid10yearsago."
Onereasonthatsubspecialistsaredoingprimarycareproceduresisthatinsomeareastherearen'tenoughgeneraliststogoaround,says
Fayetteville,Tennessee,internistJ.FredRalstonJr.,MD,presidentoftheAmericanCollegeofPhysicians.AccordingtoAmericanCollegeof
Physiciansfigures,approximately30%ofUSphysiciansareprimarycaredoctors;inotherpartsoftheworld,thatnumberiscloserto50%.
Theextenttowhichsubspecialists"co-opt"generalists'patientsvariesfromlocationtolocation,oftendependingontheavailabilityof
generalistsandthecompetitiveatmosphere,Ralstonnotes.It'slesscommoninunderpopulated,poorlyservedareas,andmorecommonin
denselypopulatedareaswherephysiciansmustcompeteforpatients.
When a Referral Becomes a Surrender
"Gonearethedayswhenyousentapatienttoasubspecialist,theymadesuggestionsandrecommendations,thensentthepatientbackto
youtoprovidecare,"saysaninternistinthesouthwestwhoaskednottobenamed."It'sveryclearthatawell-trainedsubspecialistcanalso
beanexcellentgeneralist."
"TheproblemisthatmostofthemlearnedlongagothatstayingintheendoscopysuiteorcathlabisfarmorelucrativethandoingE&M
services.Thefrequencywithwhichsubspecialistssetupreturnvisitsandtakeovermanagementofprimarycareproblemsisunprecedented.
Somearedoingitforpatientconvenience.Othersaredoingittomakeupforeconomiclosseselsewhere."
Somesubspecialistsaremorelikelythanotherstoholdontopatients.WayneS.Strouse,afamilypractitionerinPennYan,NewYork,
expressesannoyancewithendocrinologistswho"followstablediabeticsorstablepatientswiththyroiddisease,whentheyaresimplyreviewinglabsandmakingminoradjustmentstomedicationsthatIcouldeasilydo.Thiscausestheirschedulestofillupandmakesitdifficult
togeturgentcasesseen.Itbecomesa'catch22'inthatpatientsareafraidtostopgoingtoasubspecialistforfearthatwhentheyreallyneed
him,theywon'tbeabletobeseenformonths.Ofcourse,ifalloftheappropriatepatientswerereturnedtotheirprimaryphysiciansforroutine
care,thesubspecialist'sschedulewouldopenupandpatientscouldbeeasilyaccommodated."
Other Irritating Aspects
Evenmoreannoyingtoprimarycaredoctorsiswhensubspecialistsretainreferredpatients,butdon'tseethepatientsthemselves.According
toJ.ScottJordan,MD,afamilyphysicianinWhiteHouse,Tennessee,"Severalendocrinologistsandcardiologistsbeginactingasour
patients'primarycarephysician.Therealkickeristhatmostofthesespecialistsareutilizingmidlevelproviderstomanagethepatients.My
patientscomplainaboutthisapproachandwehavetoadjustourreferrals,butsomepatientsjustdoastheyareinstructedandfollowupwith
thespecialistsasrecommended."
Incertaincircumstances,subspecialistssay,PCPsaregladtocederoutinecaretothem.AccordingtoMarcNuwer,MD,aneurologistinLos
Angeles,"Icareformanypatientswithepilepsy.Thoseintheirteensthrough40softenusemeastheironlyphysician.Someover50doso
too,butthereIprefertosharedutieswithaninternist.Otherwise,Icarefortheroutinemedicalissues,cancerscreening,andother
preventivehealthissueasifIwereaninternist.IamafellowoftheAmericanCollegeofPhysicians,andIthinkofmyselfasaninternistina
way."
Authors and Disclosures
Author(s)
Gail Garfinkel Weiss, MSW
Freelancewriter,Merrick,NewYork
Disclosure:GailGarfinkelWeiss,MSW,hasdisclosednorelevantfinancialrelationships.
zGGGzGGwaGwGjGGzGailGarfinkelWeiss,MSW
Posted:08/09/2010
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Dr.Ralstonagreesthatsometimesit'sbetterforallconcernedifasubspecialistassumesprimarycareduties--foratime."Incasesof
patientswithkidneyfailurewhoareondialysis,it'sappropriateforthenephrologisttoalsobetheirprimarycarephysician,"hesays.
"Sometimesaparticularillnesstakesovereverything.Oneofmypatientshadcoloncancerthattheoncologistmanagedwhilehewasunder
treatment.Afteraboutayear,whenthosetreatmentstaperedoff,hecamebacktometoreestablishcare."
Patients With 1 Primary Care Doctor too Many
Ingeneralists'views,akeyfactoriswhethersubspecialists,aftertreatingreferredpatients,knowwhentostepaside.SomePCPsthinkthat
subspecialistscrossthelinewhentheybegincoordinatingcareforpatientswhohaveaPCPwho'swillingandabletotakecharge.
MitchellCohen,MD,aninternistinElma,Washington,offersanexample:"Isendapatienttoacardiologistforevaluationofchestpain,and
whilethepatientistherethecardiologistnoticesthatshehasaskinlesiononherback.Insteadofsuggestingthatthepatientreturntometo
evaluatethelesion,thecardiologistrefershertoadermatologist.Notonlydoesthisresultinthepatientwaitingmorethan3monthstobe
seenbythedermatologistinsteadofmaybeaweekforme,italsorobsmeofpotentialrevenueandshowsalackofrespectfor--and
knowledgeof--myscopeofpractice."
JeffreySchultz,MD,afamilyphysicianinBaltimore,Maryland,callsthisapproach"specialistre-referral"andsays,"Sendingpatientsfrom
thespecialist'sofficetodifferentdoctorsIhavenorelationshipwith,andgetnoreportsbackfrom,makingitsonoonedoctorknowswhatis
happeningtothepatient,whatmedicinestheyaretaking,whatteststheyhavehad--isarecipefordisaster."
AccordingtoLoriHeim,MD,presidentoftheAmericanAcademyofFamilyPhysiciansandahospitalistinLaurinburg,NorthCarolina,
subspecialists'understandabletendencytofocusontheirareasofexpertisemakesthemlesslikelytoidentifyproblemsinotherareas.
"Manyofourpatientshavemultipleconditions--perhapsacombinationofdiabetes,hypertension,anddepression,"shesays."Ican'ttellyou
thenumberofpatientswho,ifthey'reonlyseeingasubspecialist,havenoanswertoquestionssuchas,Whenwasyourlastmammogram?
Whenwasyourlastpapsmear?Whenwasyourlastcolonoscopy?Whenwereyoucounseledaboutquittingsmoking?Youseem
depressed;hasanybodyaskedyouaboutthat?"
Theotherpartofthisequationiscost.Heimcitestheproverb,"Itistempting,iftheonlytoolyouhaveisahammer,totreateverythingasifit
wereanail."Shecontinues,"Aguywithchestpainsisevaluatedbyacardiologistwhofindsnoevidenceofaheartproblem.Theguythen
getsreferredtoagastroenterologist,afterwhichheseesapulmonologist--eachtimeundergoingasuccessionofexpensive,time-
consumingtests,allofwhicharenegative.FinallyheseesaPCPwho,inlookingatthepatientfromageneralistperspective,zeroesinona
musculoskeletalproblem.Sodiagnosisandtreatmentaredelayed,andthepatientrunsuphugemedicalbillsbecauseeveryonewaslooking
onlyattheirpieceofthepuzzle."
Patients Who Prefer 1-Stop Shopping
AndrewM.Star,MD,anorthopaedicsurgeoninWillowGrove,Pennsylvania,acknowledgesthat"Wecontinuetoseelargenumbersof
patientswhoskiptheirprimaryphysicianandcomedirectlytous."Starmaintainsthat"wehavealwaysdealtwiththisissuetoadegreeand
ithasalwaysworkedoutwellintheend.Weareperceivedastheultimateexpertssothepatientswhoneedusfindus."
Still,somesubspecialistsarecarefulnottotreadintoprimarycareterritory.SivaprasadD.Madduri,MD,aurologistinPoplarBluff,Missouri,
notesthatoncehetakescareofreferredpatientsandtheyarestable,headvisesthemtogobacktotheirprimarycarephysician--although
somefailtodoso.
Onereasonisthatmanypatients,eventhosewithoutseriousconditions,prefer1-stopshopping,soifthey'reseeingasubspecialistregularly
theymighttrytogetthatphysiciantohandletheirothermedicalneeds.AccordingtoSharonPacker,MD,apsychiatristinNewYorkCity,
patientsaskhertodiagnosenon-psychiatricproblemstosaveco-paysortoavoidtheinconvenienceofschedulingappointmentswithother
physicians.
"Iremindthemthatmyexpertiseingeneralmedicineis35yearsold--butmyexpertiseinpsychiatryis35minutesold,sinceIgetemail
updatesalldaylong,"shesays."AndthenIreferthembacktotheirdoctors.OrIfindthemaprimarycarephysicianiftheydon'thaveone.Ibelievethathelpingapsychiatricpatientsecuregoodmedicalcareisanotherwaytoimprovetheirmental--aswellastheirphysical--
health."
And"patientstealing"islessofaprobleminareaswherereferral-basedHMOshavetakenhold."Iusedtohavemoretroubleyearsagowith
specialistspoachingpatientsfromus.Now,duetomanagedcare,patientscan'tkeepgoingtosubspecialistswithoutareferralfromme,"
saysStevenGitler,MD,afamilyphysicianinCamden,NewJersey.
"IfapatientisrequestingareferralthatIdon'tthinkiswarranted,IwillexplaintothepatientthatIcanmanagemaintenancecareand
treatmentoftheirconditionandthatitisn'tnecessarytokeepreturningtothespecialist,"saysGitler."Mostpatientsarequitehappytohear
thatsinceinthisareaspecialistco-paysaretypicallyhigherthanprimarycareco-pays.Itisalsomucheasiertogetanappointmentwithme
thanwiththesubspecialists."
The Generalist as Specialist
The"patientco-option"meterswingsbothways.
Primarycarephysicians--anxioustoincreaseincome--moveintoterritoryonceoccupiedalmostexclusivelybysubspecialists.Whenthe
AmericanAcademyofFamilyPhysicianssurveyeditsmembersin2008abouthospitalservicestheyprovide,findingsindicatedthat
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approximately35%docoronarycare,30%interpretelectrocardiograms,26%providepsychiatricservices,21%dominorsurgery,and11%
docolonoscopy.
Atthesametime,generalistsareaddingmorein-officeservices.Approximately5yearsago,familyphysiciansBethandFranciscoHodges
(bothMDs)begandoingin-houselabtestingintheirAsheboro,NorthCarolina,practice.Thetestsweresuchpatient-pleasersthatthe
Hodgesesswungintofullancillarymode.
Theynowofferbonedensitometry,pulmonaryrehabilitation,achildren'sasthmamonitoringprogram,in-officeultrasound,cardiacstress
testing,andadiabeticcounselingprogram.Laterthisyear,theyplantoaddcardiacrehabilitation,nutritionalcounseling,andotherservices.
Theresult?AccordingtoBethHodges,"Ourpatientsaremorecompliantbecauseitislessexpensive,lessintimidating,andmoreconvenient
forthemtohavethingsdonewithinourwalls."
InternistShereeB.Lipkis'ssolopracticeinGlenview,Illinois,isalsoancillary-rich.Inadditiontoemployinganursepractitioneranda
neuromusculartherapist,shedoesHolterandeventmonitoring,aswellasultrasounds."Inmyopinion,theonlywaythatnon-concierge
primarycarephysicianscanstayafloatfinanciallyistobemoreprocedure-oriented,becausewearereimbursedbetterforproceduresthan
forthinkingthroughandmanagingapatient'sproblems,regardlessofhowcomplex,"saysDr.Lipkis.
WayneS.Strouse,MD,inPennYan,avillageof6000intheNewYorkFingerLakesregion,mentionspatientconvenienceashismain
motivationfordoingnon-generalistwork.Becausethenearestbigcity,Rochester,isabout90minutesaway,hisprofessionalrepertoire
includespsychiatricanddermatologicalservices.
Financial Challenges Arise
Somesubspecialistsarefeelingthepinch.M.P.RavindraNathan,MD,acardiologistinBrooksville,Florida,saysthatmanyPCPsinhisarea
haveechomachinesandstresstest/nuclearimagingfacilities,anddocarotidandperipheralvascularstudies."Onelargefamilypractice
groupissowell-equippedthattheircardiologyreferralstomehaveceased,"hesays.
Forthemostpart,generalistswhohavesuccessfullybeefeduptheirpracticeswithservicestheyusedtoreferouthavean"all'sfair"attitude,
notingthatsubspecialiststypicallyout-earngeneralists."Medicinehasovervaluedproceduresasopposedtojustface-to-facevisits,"says
LoriHeim,"Primarycarephysicianswhoreferoutthoseproceduresareinfactlosingrevenue."
Anoptimumprimarycaresetting,saystheAmericanCollegeofPhysicians'FredRalston,ispatient-centeredmedicalhomes,inwhich
patientshaveanongoingrelationshipwithapersonalphysicianwhocoordinatescareacrossallaspectsofthehealthcaresystem.Thatwill
attractmorephysicianstoprimarycare,saysRalston,andmakeiteasierforpatientstogettheprimarycare,andthesubspecialistreferrals,
theyneed.
Determining Who's in Charge
Whatshouldgeneralistsdoiftheyfeelasubspecialistisunnecessarilyencroachingontheirterritory?"OntherareoccasionwhenInoticea
patternofpatientsbeingreferredtoaparticularsubspecialistandnevercomingbacktome,Iwon'thesitatetostopusingthatspecialist,"
saysfamilypractitionerStevenGitler.OccasionallyGitlerwillcallthedoctor."I'lllethimknowthatI'mreferringpatientsforevaluationandI'd
likethemsentbacktomeoncetheirconditionisstabilized,"hesays
Dr.Ralstonrecommendsthatgeneralistsstartwithaphonecalloraletteroutliningtheirconcernsandindicatingwhyitisinthepatients'best
interestforthemtoreturntotheirprimarycaredoctor.
AmericanAcademyofFamilyPhysicianspresidentLoriHeimalsosuggeststakingadiplomatictack--forstarters."Ifthesubspecialist
doesn'treferthepatientbacktotheprimarycarephysicians,thePCPshouldcontactthesubspecialistanddiscussthis,"shenotes."BeforeI
becameahospitalist,that'swhatdidifIreferredapatientanddidn'tgetatimelycommunicationbackastotheirdiagnosis,treatment,and
conclusions.Thesubspecialist'sresponsewouldhaveadefinitiveinfluenceonfuturereferralsfromme."
Heimcontinues,"Sometimesthesubspecialistsaysthatpatientsprefertoremainwiththem,butthat'sprobablynotthecaseifthereisa
patternofprolongedcareandthepatientsaren'tfollowingupwiththeirprimarycarephysician.Ifoundthatmostofmypatientsinsistedon
comingbacktometoconfirmthattheyshouldfollowtheadviceofthesubspecialist."
LikeRalston,Heimpointstotheneedforthepatient-centeredmedicalhomewhere,shesays,"wealignthefinancialincentivesaround
qualitypatientcareandnotjustonthevolumeofproceduresorvisits."
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