HSMA 4075-Managed Care in Health Systems

Gynecologists as the Primary Care Physician?

Sonya M. Artis

September 11, 2008

Gynecologists as the Primary Care Physician?

In managed health care the primary care physician has a role that is very significant to the delivery of care. A primary care physician serves as the initial contact for a person with an undiagnosed medical concern and they are responsible for the continuum of care for varied existing medical conditions. These conditions are not limited by diagnosis, organ system, or cause. Ordinarily, a primary care physician does not specialize in any medical specialty, such as neurology, oncology, pulmonology, or gastrology. However, the concept of the gynecologist as the primary care physician remains arguable. In comparison to the primary care physician the obstetrics/gynecologist also plays a vital role in the health care treatment plan---for women. As a result, some managed care organizations (MCOs), health maintenance organizations (HMOs) and indemnity health insurers may allow the gynecologist as the primary care physician.

According to Kongstvedt, many obstetrics/gynecologists (OB/Gyn) feel as if they indeed deliver primary care. They make this assertion because “they are often the only physician a young woman sees for many years” (66). Healthy women do not always have medical concerns until problems arise with their female reproductive systems. Therefore, care provided by the OB/Gyn could be viewed as primary care. Yet, are they willing to take on the extra responsibility? Because “ in the early 1990’s, there was at least one program designed to retrain OB/Gyn physicians to provide a broader range of primary care, but the results were quite disappointing, with a very high dropout rate and a high level of dissatisfaction with broad primary care expressed” (66). This could be partially because of the initial basis that gynecology is indeed a specialty without adding primary care to the equation. At any rate, “as of 2002 59% of reporting HMOs and point-of-service plans (POS) allowed members to use OB/Gyns as their primary care coordinator, though it is not clear if those same numbers would apply to HMO-only health plans” (66).

Furthermore, an article by Lentz et al investigated the impact of physician use patterns on women’s receipt of preventive care services such as recommended screening, counseling, and heart disease prevention services. Although the OB/Gyn as the primary care physician shows promise, overall health is a legitimate concern. As stated earlier by Kongstvedt, OB/Gyns are resistant to the broadness in average primary care physician work. The results showed that”58% of women reported using two physicians (a generalist and a gynecologist) for regular care received more preventive services, which included heart disease screening” (Lentz et al). This is an important factor when exploring the idea of the OB/Gyn as the primary care physician.

One issue that Kongstvedt failed to consider that Lentz et al did was disproportion. Lentz et al found that within the integrated women’s health care setting, OB/Gyns and internal medicine primary care physicians provided care to patients with significantly different demographic characteristics and diagnosis. They observed that women who were treated by OB/Gyns were more likely to be younger and have gynecologic diagnoses when compared with women treated by internal medicine physicians (Lentz et al). Additionally, OB/Gyns saw fewer diagnoses that were consistent with providing primary care such as hypertension, sinusitis, depression, or back pain (Lentz et al). For instance, Kongstvedt merely asserts that, “the OB/Gyn may be seen without referral for Pap smears and pelvic examinations, for pregnancy, for sterilization procedures, and so forth; and for clinical care that is out of the scope of normal OB/Gyn practices, the member must see the primary care physician for either treatment by or referral to any other specialist” (67), meanwhile overlooking the demographic aspect.

On the other hand, these opinions and statistics generated by Kongstvedt and Lentz et al could be caused by the familiarity that women have with their OB/Gyns and not because women only see them when female reproductive problems erupt. Total women’s wellness and disease prevention can only be preserved through regular screening practices as encouraged by the regular PCP. Realistically, in order for the OB/Gyn to actually serve as the primary care physician pre-authorization and referral control will need to be established. In fact, “most all plans allow direct access to OB-Gyns for female members, even those that capitates primary care” (Kongsvedt, 66). Therefore, being seen by a OB/Gyn is just as easily accessible in most plans as the primary care physician. The PCP and the OB/Gyn share clinical care (and perhaps the capitation, if that is the reimbursement system in use) between the OB/Gyn and the internist or general practitioner (67). Both the OB/Gyn and the primary care physician seem to complement each other where women’s health is concerned. So, the truth lies in the type of managed care plan or health care insurance the member has as well as the willingness of the OB/Gyn to provide primary care if they had pre-authorization and referral control.

In conclusion, it shows that overall women’s health can be achieved by the collaboration of the primary care physician and the OB/Gyn. The primary care physician should remain the first medical practitioner contacted by a patient, due to factors such as accessible locations, communication across the continuum of care, and increasingly issues of cost and managed care requirements. Likewise, the OB/Gyn needs to remain direct access for female members for female reproductive care. Although the OB/Gyn’s scope of practice can certainly advocate overall women’s health, it does not address other health care concerns such as diabetes, depression, lung cancer, bronchitis, and more issues that require other specialty care. HMOs, private insurance, and most health care plans already seem to have come to the realization that members need access to OB/Gyn care. However, most OB/Gyns do not seem to have come to the realization that broader services for their scope of practice could be beneficial to women’s overall health.

Reference Page

Lentz M, Gretchen, MD, Ayala, Leticia, Eckert, Linda O. American Journal of Obstetrics & Gynecology. A Comprehensive Women’s Health Care Center: Are Gynecologists Offering Primary Care. 2006; 194, 1660-7

Kongstvedt, Peter R. Essentials of Managed Health Care: 5th ed. Sudbury, MA: Jones and Bartlett Publishers; 2007: 66-67

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