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Direct access—another assault
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Direct access
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III
another assault
The gatekeeper concept, whereby the patient has to be physician-referred to a specialist rather than self-referred, is usually associated with HMOs. However, this is only the tip of the iceberg, as a recent publication I amply indicates. This 177-page document represents the proceedings of a conference sponsored by an independent agency, the Center for Policy Research of the National Governors' Association. The thrust of the report is the development of a "Primary Care Network" (PCN) as a method of Medicaid cost containment. What is a PCN? The following verbatim quote from the report succinctly describes such an entity. In general, a Primary Care Network (PCN) has three characteristics: (1) it consists of primary care physicians dispersed throughout the community in solo or group practices, (2) patients are enrolled in the PCN and assigned to a single primary care physicians (sic), and (3) the network increases control that the primary care physician has over the total medical care received by the patient. The PCN is a cost-containment measure that is proposed by the conference participants as an alternative to conventional Medicaid programs. Already a mandatory experimental plan such as that proposed and which is called the "Experimental Michigan Plan" is being set up for Medicaid patients in Wayne County, MI. However, the PCN concept goes much beyond this and may eventually extend to Medicare and private business employee groups. For instance: (1) a new experimental, but still voluntary PCN has been proposed for Medicare patients in Baldwin County, GA, and (2) Arizona's experimental PCN Medicaid plan is slated to cover private employee groups "sometime in the future" after it is in place for the more traditional indigent population, according to an Arizona official. No matter what the official line is, the PCN
398
I
concept is essentially a pattern of health care delivery comparable to that of the British National Health Service and, if allowed to proliferate, would subvert or severely cripple our fee-for-service system and threaten to eliminate the freechoice of physician option, both of which are essential characteristics which distinguish our health care system from the regulated systems we refer to as socialized medicine. The reasons are quite clear if one examines the PCN system carefully. The key is the fact that the primary care physician serves as a gatekeeper with financial disincentives to use referring physicians. The total medical care of the patients assigned to an individual primary care physician is his or her responsibility, and if extra expenses result from referral, this will mean less income for the primary care physician. Statements about the PCNs as detailed in the report included the following comments: (1) "There will be no payment for non-emergency self-referral"; (2) "maintained responsibility and control by the primary care physician may be one of the most effective ways that health care can be contained without building a new system from the bottom up or overburdening the existing system with excessive constraints and controls"; (3) "there needs to be a better system whereby the primary care physicians can confront and get tough with the specialists"; and (4) "the system has to be monitored to eliminate those with excessive referral patterns." Those who would attempt to justify the gatekeeper role of the primary care physician consistently refer to the importance of having a single physician responsible for coordinating the health care for all patients and their families. We would, however, stress that, whether or not one agrees with this, it should be a voluntary system and promoted through education and not regulation. If then there is validity to this concept, it should be possible to convince patients rather than impose such a pattern of care by administrative fiat. Fur0190-9622/82/090398+02500.20/0 © 1982 Am Acad Dermatol
Volume 7 Number 3 September, 1982
thermore, the question must also be asked as to whether imposition of such a system may not in fact reduce the quality of care, since, if a primary care physician is automatically guaranteed a patient clientele and is no longer forced to compete with specialists for patient acceptance, what incentive is there for that physician to maintain or improve the quality of care he or she delivers? There is a prevalent belief among health policy experts that primary care physicians deliver more cost-effective care than specialists and thus serve as the best managers. This belief has never been substantiated by any data and, in fact, is open to question in regard to dermatologic care since preliminary evidence from two independent studies ''a suggests that primary care physicians fail to diagnose correctly 40% to 50% of the twenty most common dermatoses. We, as dermatologists, should be aware of the significance of the PCN concept. Should there be any doubt that the gatekeeper pattern is viewed by the conference participants as the pivotal element, it should be removed by the following quote from the conference summary on page 163 of the conference report: "The key is that the primary phy-
Direct access--another assault
399
sician is the gatekeeper, and we've heard that phrase over and over today." We must continue to support activities of the American Academy of Dermatology that are actively confronting the direct access problem. This is not a simple task. It will require the development of several different projects and undoubtedly will require significant financial support. The time to act is now.
Peyton E. Weary, M.D. Charlottesville, VA John S. Strauss, M.D. lowa City, IA REFERENCES l. Medicaid and Primary Care Networks; a concept paper and the Proceedings of the NGA Conference on Medicaid and Primary Care Networks/Case Management Systems, December 2, 1981. Document available from: State Medicaid Information Center, Center for Policy Research, National Governors' Association, 444 North Capitol St., Washington, DC 2000t. March, 1982. 177 pages. 2. Ramsay DC, Fox AB: The ability of primary care physicians to recognize the common dermatoses. Arch Dermatol 117:620-622, 1981. 3. Clark RA, Rietschel RL: The cost effectiveness of treating skin diseases. (To be submitted for publication.)
Illl II
Ill
Direct access
I
Ill
III
III
another assault
The gatekeeper concept, whereby the patient has to be physician-referred to a specialist rather than self-referred, is usually associated with HMOs. However, this is only the tip of the iceberg, as a recent publication I amply indicates. This 177-page document represents the proceedings of a conference sponsored by an independent agency, the Center for Policy Research of the National Governors' Association. The thrust of the report is the development of a "Primary Care Network" (PCN) as a method of Medicaid cost containment. What is a PCN? The following verbatim quote from the report succinctly describes such an entity. In general, a Primary Care Network (PCN) has three characteristics: (1) it consists of primary care physicians dispersed throughout the community in solo or group practices, (2) patients are enrolled in the PCN and assigned to a single primary care physicians (sic), and (3) the network increases control that the primary care physician has over the total medical care received by the patient. The PCN is a cost-containment measure that is proposed by the conference participants as an alternative to conventional Medicaid programs. Already a mandatory experimental plan such as that proposed and which is called the "Experimental Michigan Plan" is being set up for Medicaid patients in Wayne County, MI. However, the PCN concept goes much beyond this and may eventually extend to Medicare and private business employee groups. For instance: (1) a new experimental, but still voluntary PCN has been proposed for Medicare patients in Baldwin County, GA, and (2) Arizona's experimental PCN Medicaid plan is slated to cover private employee groups "sometime in the future" after it is in place for the more traditional indigent population, according to an Arizona official. No matter what the official line is, the PCN
398
I
concept is essentially a pattern of health care delivery comparable to that of the British National Health Service and, if allowed to proliferate, would subvert or severely cripple our fee-for-service system and threaten to eliminate the freechoice of physician option, both of which are essential characteristics which distinguish our health care system from the regulated systems we refer to as socialized medicine. The reasons are quite clear if one examines the PCN system carefully. The key is the fact that the primary care physician serves as a gatekeeper with financial disincentives to use referring physicians. The total medical care of the patients assigned to an individual primary care physician is his or her responsibility, and if extra expenses result from referral, this will mean less income for the primary care physician. Statements about the PCNs as detailed in the report included the following comments: (1) "There will be no payment for non-emergency self-referral"; (2) "maintained responsibility and control by the primary care physician may be one of the most effective ways that health care can be contained without building a new system from the bottom up or overburdening the existing system with excessive constraints and controls"; (3) "there needs to be a better system whereby the primary care physicians can confront and get tough with the specialists"; and (4) "the system has to be monitored to eliminate those with excessive referral patterns." Those who would attempt to justify the gatekeeper role of the primary care physician consistently refer to the importance of having a single physician responsible for coordinating the health care for all patients and their families. We would, however, stress that, whether or not one agrees with this, it should be a voluntary system and promoted through education and not regulation. If then there is validity to this concept, it should be possible to convince patients rather than impose such a pattern of care by administrative fiat. Fur0190-9622/82/090398+02500.20/0 © 1982 Am Acad Dermatol
Volume 7 Number 3 September, 1982
thermore, the question must also be asked as to whether imposition of such a system may not in fact reduce the quality of care, since, if a primary care physician is automatically guaranteed a patient clientele and is no longer forced to compete with specialists for patient acceptance, what incentive is there for that physician to maintain or improve the quality of care he or she delivers? There is a prevalent belief among health policy experts that primary care physicians deliver more cost-effective care than specialists and thus serve as the best managers. This belief has never been substantiated by any data and, in fact, is open to question in regard to dermatologic care since preliminary evidence from two independent studies ''a suggests that primary care physicians fail to diagnose correctly 40% to 50% of the twenty most common dermatoses. We, as dermatologists, should be aware of the significance of the PCN concept. Should there be any doubt that the gatekeeper pattern is viewed by the conference participants as the pivotal element, it should be removed by the following quote from the conference summary on page 163 of the conference report: "The key is that the primary phy-
Direct access--another assault
399
sician is the gatekeeper, and we've heard that phrase over and over today." We must continue to support activities of the American Academy of Dermatology that are actively confronting the direct access problem. This is not a simple task. It will require the development of several different projects and undoubtedly will require significant financial support. The time to act is now.
Peyton E. Weary, M.D. Charlottesville, VA John S. Strauss, M.D. lowa City, IA REFERENCES l. Medicaid and Primary Care Networks; a concept paper and the Proceedings of the NGA Conference on Medicaid and Primary Care Networks/Case Management Systems, December 2, 1981. Document available from: State Medicaid Information Center, Center for Policy Research, National Governors' Association, 444 North Capitol St., Washington, DC 2000t. March, 1982. 177 pages. 2. Ramsay DC, Fox AB: The ability of primary care physicians to recognize the common dermatoses. Arch Dermatol 117:620-622, 1981. 3. Clark RA, Rietschel RL: The cost effectiveness of treating skin diseases. (To be submitted for publication.)