Women's access to appropriate providers within managed care: implications for the quality of primary care.

Summary Women receive care for common acute and chronic illnesses from family physicians/general practitioners and internists and preventive care and reproductive-related care from gynecologists. In addressing the issue of appropriate providers, then, current information about use and practice variation would suggest that many women require an arrangement that offers access to a family physician and/or internist as well as a gynecologist to receive a full complement of care. In fact, those women respondents in the Commonwealth Fund Survey of Women's Health who saw both a family physician/general practitioner or internist and an obstetrician/gynecologist for regular care were most likely to receive more preventive services. 4 However, although this arrangement increases a women's potential to receive comprehensive care, it reduces opportunities for continuous and coordinated care. A reliance upon more than one physician throughout a woman's life to deliver both preventive care and therapeutic care is not compatible with existing models of primary care and may be problematic in managed care arrangements that require women to use specific providers. In addition, requiring more than one physician to obtain the majority of one's health care services is likely to result in increased direct and opportunity costs. Women without adequate insurance or financial resources may be unable to seek care from one, let alone two, physicians and therefore may be at higher risk of not receiving needed or necessary care. Nonetheless, women are satisfied with a dual arrangement and articulate strong preferences for maintaining access to gynecologists and to family physicians and internists. Alternatively, women may realize that this arrangement is necessary to obtain needed services, particularly screening for cervical and breast cancer, gynecologic care, and contraception. If these practice patterns continue, any limitation on women's access to providers places them at increased risk of not receiving a full complement of care. If a dual or multiple provider arrangement of primary care persists, however, there will be little incentive for physician specialty groups to acquire or maintain a broad range of diagnostic, preventive, and therapeutic skills. Simple or arbitrary designation of primary care providers without assurances that training and practices undergo modifications may only increase the magnitude of the problem of fragmentation of care. 21 In addition, the identification of multiple primary care specialties as primary care providers will affect workforce and reimbursement policies. Much of the available data about practice patterns and use were gathered prior to the expansion of managed care systems. Future studies will help to delineate the influence of managed care on patient preferences and provider practices and determine which arrangements of primary care for women are efficient and result in resource-savings, quality care, and patient satisfaction. Ultimately, as integrated delivery systems expand, considerations of women's preferences and costs will need to be balanced. Future studies will be necessary to examine the effect that managed care has on the practice patterns of these three physician specialty groups, as well as the quality of primary care that women receive.