Changes in the scope of care provided by primary care physicians

Background: Strategies to control medical costs and improve the quality of care often translate into decisions affecting the range of services primary care physicians provide to patients, which patients are referred for specialty care, and the points in disease processes at which referrals are made. This study focused on physicians' assessments of changes in the scope of care provided by primary care physicians and their assessments of the appropriateness of the scope of the care that primary care physicians are expected to provide. Methods: We analyzed data from the 1996-1997 Community Tracking Study Physician Survey. Telephone interviews were conducted with 12,385 physicians (reflecting a response rate of 65 percent) who were drawn from a representative random sample of physicians providing direct patient care in the continental United States and not employed by the federal government. The analysis was based on responses from the 7015 primary care physicians and 5092 specialists who had been in practice for at least two years. Results: Thirty percent of the primary care physicians and 50 percent of the specialists reported that the scope of care provided by primary care physicians had increased during the previous two years. Twenty-four percent of the primary care physicians and 38 percent of the specialists reported that the scope of care expected to be provided by primary care physicians was greater than it should be. According to multivariate analysis, primary care physicians other than general or family practitioners (i.e., pediatricians and general internists), those who were in one- or two-physician practices, those who received revenues from capitation, and those who served as gatekeepers for their patients' care were significantly more likely to report that the scope of care they were expected to provide was greater than it should be. Conclusions: The finding that nearly one in four primary care physicians reported that the scope of care they were expected to provide was greater than it should be arouses concern about the potential impact of changes in the delivery of health care. The associations we found between financial and administrative aspects of managed care and physicians' concern about the scope of care they provide to their patients deserve careful consideration. (N Engl J Med 1999;341:1980-5.) (C)1999, Massachusetts Medical Society.