Financial Challenges Arise
Some subspecialists are feeling the pinch. M.P. Ravindra Nathan, MD, a cardiologist in Brooksville, Florida, says that many PCPs in his area have echo machines and stress test/nuclear imaging facilities, and do carotid and peripheral vascular studies. "One large family practice group is so well-equipped that their cardiology referrals to me have ceased," he says.
For the most part, generalists who have successfully beefed up their practices with services they used to refer out have an "all's fair" attitude, noting that subspecialists typically out-earn generalists. "Medicine has overvalued procedures as opposed to just face-to-face visits," says Lori Heim, "Primary care physicians who refer out those procedures are in fact losing revenue."
An optimum primary care setting, says the American College of Physicians' Fred Ralston, is patient-centered medical homes, in which patients have an ongoing relationship with a personal physician who coordinates care across all aspects of the healthcare system. That will attract more physicians to primary care, says Ralston, and make it easier for patients to get the primary care, and the subspecialist referrals, they need.
Determining Who's in Charge
What should generalists do if they feel a subspecialist is unnecessarily encroaching on their territory? "On the rare occasion when I notice a pattern of patients being referred to a particular subspecialist and never coming back to me, I won't hesitate to stop using that specialist," says family practitioner Steven Gitler. Occasionally Gitler will call the doctor. "I'll let him know that I'm referring patients for evaluation and I'd like them sent back to me once their condition is stabilized," he says
Dr. Ralston recommends that generalists start with a phone call or a letter outlining their concerns and indicating why it is in the patients' best interest for them to return to their primary care doctor.
American Academy of Family Physicians president Lori Heim also suggests taking a diplomatic tack -- for starters. "If the subspecialist doesn't refer the patient back to the primary care physicians, the PCP should contact the subspecialist and discuss this," she notes. "Before I became a hospitalist, that's what did if I referred a patient and didn't get a timely communication back as to their diagnosis, treatment, and conclusions. The subspecialist's response would have a definitive influence on future referrals from me."
Heim continues, "Sometimes the subspecialist says that patients prefer to remain with them, but that's probably not the case if there is a pattern of prolonged care and the patients aren't following up with their primary care physician. I found that most of my patients insisted on coming back to me to confirm that they should follow the advice of the subspecialist."
Like Ralston, Heim points to the need for the patient-centered medical home where, she says, "we align the financial incentives around quality patient care and not just on the volume of procedures or visits."
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Cite this: Gail Garfinkel Weiss. Smile as You Steal my Patient: Primary Care vs Specialists - Medscape - Aug 09, 2010.