BACKGROUND: Federal legislation has recently been proposed to designate obstetrician-gynecologists (OBGs) as primary care physicians. The Institute of Medicine identifies care unrestricted by problem or organ system as an essential characteristic of primary care. We examined the degree to which OBGs in the state of Washington offer this aspect of primary care to their elderly patients by investigating the type and amount of nongynecologic care they provide.
METHODS: Using 1994 Part B Medicare claims data for Washington residents, we identified visits made by women aged 65 years and older to OBGs (N=10,522) and 9 other types of specialists. Diagnoses were classified as in or out of the domain of care traditionally provided by each specialty. Visit volumes, proportion of out of domain visits, and the frequency of diagnoses were reported.
RESULTS: Of the patient visits to obstetrician-gynecologists, 12.2% had nongynecologic diagnoses. The median percentage of nongynecologic visits for individual OBGs was 6.7%. Patients who saw OBGs received 15.4% of their overall health care from an OBG; patients who saw family physicians received 42.9% of their total health care from a family physician.
CONCLUSIONS: In 1994, a small amount of the care that Washington OBGs provided to their elderly patients was for nongynecologic conditions. Studies are needed to evaluate how the practices of OBGs have changed since the 1996 implementation of a primary care requirement in obstetrics-gynecology residencies, and if adopted, how legislation designating OBGs as primary care physicians affects the health care received by elderly women.
The growth of managed health care organizations and their emphasis on the use of primary care providers as gatekeepers has radically changed the value of a specialty designated as a provider of primary care. Classification as a primary care physician has become important to physicians because it provides a patient base and source of revenue, and it is important to patients because it allows direct access to those physicians.1 For the most part, general internists, family physicians, and pediatricians are designated as primary care specialists. Increasingly, however, there have been efforts at the state and federal levels to designate obstetrician-gynecologists (OBGs) as primary care providers for women. A bill was introduced in 1999 before both houses of the 106th Congress (S. 6 and H.R. 358, The Patients’ Bill of Rights Act of 1999) that would allow women to choose OBGs as their primary care physicians, and it is still awaiting action.
Traditionally, the specialty of obstetrics-gynecology has considered itself expert in the areas of reproductive health and gynecologic diseases.2-4 Recently, changing practice philosophy has resulted in an increasing emphasis on providing general medical care.5-7 In 1993, the American College of Obstetricians and Gynecologists (ACOG) formed a Task Force on Primary and Preventive Healthcare that identified 3 levels of care that can be provided by OBGs: traditional specialty care, primary preventive care, and extended primary care.8 OBGs providing primary preventive care take a broader role in health maintenance for women, including health screening and disease prevention. Those providing extended primary care offer primary preventive care and treat medical conditions beyond those pertaining to the reproductive system. Although OBGs have been divided over their role as primary care physicians, a primary care requirement in residency training was implemented in 1996.3,5
The Committee on the Future of Primary Care of the Institute of Medicine (IOM) defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs.”9 Included in the description of integrated is comprehensive, which means providing care for any health problem at any given stage of a patient’s life cycle. Addressing the majority of health care needs refers to the primary care physician receiving all problems that patients bring—unrestricted by organ system—and having the appropriate training to diagnose and manage the majority of them. Caring for a broad spectrum of medical problems encompassing many organ systems is a component of primary care, and this component is what is included in the ACOG definition of extended primary care. Throughout this article the term primary care will be used to represent the broad-spectrum care accepted by the IOM and ACOG as an element of primary care.
Few studies have measured the degree to which OBGs provide primary care.10-13 Of those that have, many are based on surveys completed by patients or physicians and are focused on women in their reproductive years. Horton and colleagues10 surveyed a national random sample of 1250 ACOG members in a variety of practices and found that more than 90% of the responding OBGs performed blood pressure screening, breast examinations, mammography, and Papanicolaou tests. Hendrix and coworkers11 reviewed 739 patient encounters from 335 charts of the private practices of faculty in the Department of Obstetrics and Gynecology at Wayne State University and found that of nonobstetrical visits, 80% were for primary gynecologic care and 7% for primary nongynecologic care. Leader and Perales12 reviewed data from a 1991 economic survey conducted by ACOG of a stratified random sample of 2000 of its members practicing in the United States. Of 1286 respondants, 48% considered themselves primary care providers. A recent study by Jacoby and colleagues14 used Medicare claims data to examine the scope of care that OBGs provided to their elderly patients. They found that OBGs provided a substantial amount of preventive care but not much nongynecologic care for elderly women.