Seeking Value in Healthcare: The Importance of Generalists as Primary Care Physicians

Primary care, a core organizing feature of developed health systems worldwide, is commonly defined as having five key components: first-contact accessibility, continuity, comprehensiveness, coordination, and whole-person focus. Generalist-trained physicians such as family medicine practitioners, general internists, and geriatricians typically provide primary care to older adults. Although health plans such as health maintenance organizations (HMOs) explicitly require enrollees to identify a primary care physician (PCP)—to provide the above functions and to serve as a “gatekeeper” in controlling access to other physicians and services—many health plans, including traditional Medicare and most preferred provider organizations, do not require enrollees to identify a PCP, and hence many enrollees, without a PCP coordinating their care. Subspecialists can explicitly serve as PCPs, although this seems to be becoming less common over time. Studies comparing the quality and efficiency of care delivered by generalist and specialist physicians have come to varied and often contradictory conclusions. When comparing quality of care using disease-specific process measures, PCPs are frequently shown to deliver lower-quality care than specialists. For instance, individuals cared for primarily by cardiologists may have higher measured quality on aspects of care directly related to cardiology, such as management of heart failure, than those cared for by PCPs. Similar findings have been shown for care of individuals with coronary artery disease, diabetes mellitus, and rheumatoid arthritis. In contrast, quality of care for aspects of care outside of the particular specialty, including delivery of preventive services, is better with generalists. In addition, research with shows that specialists who serve as PCPs generally address a smaller range of problems, suggesting that generalist PCPs might deliver morecomprehensive, whole person–focused care. Although mostly ecological in nature, additional data at the population level support the benefits of primary care–focused systems. At a system level, a greater supply of generalist physicians relative to subspecialists is associated with higher overall quality of care, and health systems with a greater primary care orientation have better health outcomes and generally lower healthcare use. In addition, for individuals with multiple chronic conditions, functional health status is similar regardless of whether generalists or specialists care for them, but generalists use fewer resources. These contradictory findings have been termed the paradox of primary care. In this issue, Bynum and colleagues make an important contribution to understanding this paradox and the value of generalists in the outpatient care of complex older adults, who often require coordinated care from physicians in multiple specialties. In a retrospective cohort study of 3,934,942 traditional Medicare beneficiaries aged 65 and older with multimorbidity (defined as having two or more of 16 prespecified chronic medical conditions), the authors compared hospitalizations, total spending, and mortality of individuals primarily receiving their care from generalists with those primarily receiving their care from subspecialty physicians. They found that specialists predominantly cared for nearly one-third of individuals in their sample and that these individuals had less continuity of care and more outpatient visits to more providers. Although there were small but not clinically meaningful differences in mortality and preventable hospitalizations between groups, all-cause hospitalizations and costs were higher in the specialist-dominant group. Inpatient stays, professional fees, and outpatient facilities drove costs. Hence, individuals who received care from generalists had similar mortality, with fewer encounters, fewer hospitalizations, and lower costs. Less is more. Although these findings are potentially important, there are a number of potential limitations to the analyses that must be considered. As previously noted, Medicare beneficiaries are not required to explicitly identify a PCP. Consequently, the authors relied on administrative claims to identify the physician providing the plurality of an enrollee’s outpatient evaluation and management visits. Approximately half of those with a specialist as their predominant provider of care were also seeing a generalist. Presumably those who have a majority of their visits with a generalist provider are receiving primary care from them, but for enrollees who predominantly see a specialist, that provider’s role is less clear. Research has shown that people often do not identify the doctor they see most as their “primary physician. ” Thus, in some cases, an individual might have been receiving primary care from a PCP but was assigned to a specialist as their predominant provider simply because he or she had more visits with that physician. For individuals with a dominant medical problem or one that had flared up during the year, it is reasonable that there could have been more visits to a specialist even when the specialist was not providing primary care. This is in contrast to cases in which the enrollee and physician would both identify the specialist as their PCP. There is therefore substantial potential for misclassification. DOI: 10.1111/jgs.14937