Ambulatory Care Provided by Office-Based Specialists in the United States

Jose M. Valderas; Barbara Starfield; Christopher B. Forrest; Bonnie Sibbald; Martin Roland

doi:10.1370/afm.949

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Free flowing commentary stimulated by the Annals article
Eugene S. Farley

Published on: 17 March 2009
A product of the current system
Christopher J Stille

Published on: 17 March 2009

Published on: (17 March 2009)
Page navigation anchor for Free flowing commentary stimulated by the Annals article
Free flowing commentary stimulated by the Annals article
Eugene S. Farley, Verona, United States
Free flowing commentary stimulated by the Annals article: Ambulatory Care Provided by Office-Based Specialists in the United States.
This paper brings up many of the original discussions that led to the development of Family Medicine as an academic discipline and Family Practice as a clinical specialty – the emphasis was on a physician who assumed primary responsibility for the ongoing care of the individual and...
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Free flowing commentary stimulated by the Annals article: Ambulatory Care Provided by Office-Based Specialists in the United States.
This paper brings up many of the original discussions that led to the development of Family Medicine as an academic discipline and Family Practice as a clinical specialty – the emphasis was on a physician who assumed primary responsibility for the ongoing care of the individual and family – this involved continuity of care and the integration of preventive care and health maintenance in with the ongoing responsibility for working with the patient, in the context of family and community, to identify and respond appropriately to those problems which affected their health and well being.
Faced with the issue of organ and disease specialists being more plentiful than specialists in Family Medicine, general Internal Medicine and general Pediatrics it makes sense to determine the role the disease and organ specialists play in health maintenance, disease prevention. This paper gives some interesting figures for that. What it does not do is let us know what is the actual nature of the “primary care” provided – is it the responsibility of providing the full content espoused for the primary physician, or is it a subset of this responsibility.
We are now using new language to describe something we have supposedly been working for over these last 40 + years, it is the “Medical Home”. It is an easily understood name, now it must be given its full meaning – some one or integrated group that assumes the primary responsibility for providing the services long espoused by and often provided by physicians in Family Practice, general Internal Medicine and general Pediatrics.
Now we need a study on how care provided by those specialties that accept the primary responsibility for the ongoing care of the individual and family does or does not differ from the “primary care” provided by disease and/or organ focused specialties.
Gene Farley
Eugene S. Farley, MD, MPH
608-845-8724
Competing interests: None declared
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Competing Interests: None declared.
Published on: (17 March 2009)
Page navigation anchor for A product of the current system
A product of the current system
Christopher J Stille, Worcester, MA USA
I read the article by Valderas et al. in this month’s Annals of Family Medicine with great interest, but little surprise. The authors point out that most outpatient specialty care visits in the United States are of a routine follow-up nature, and suggest that some of this care could be provided by primary care physicians. Additionally, they observed that only about 1 in 3 specialist visits in their sample was for a prob...
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I read the article by Valderas et al. in this month’s Annals of Family Medicine with great interest, but little surprise. The authors point out that most outpatient specialty care visits in the United States are of a routine follow-up nature, and suggest that some of this care could be provided by primary care physicians. Additionally, they observed that only about 1 in 3 specialist visits in their sample was for a problem for which they share care with another physician. As many problems are shared between specialists, rather than between a specialist and a primary care physician, this is likely an overestimate of the degree of sharing of care between primary care and specialty physicians. In any case, there appears to be a big opportunity to increase sharing of care between primary care physicians and specialists.
There exist a number of models of shared care that might ease problems with access to specialty care.1 However, there are good reasons for the existence of current patterns of care in the current fee-for- service payment system, which for non-procedure-oriented specialties typically rewards visit volume over time and effort spent per visit. For specialists, the follow-up visit is typically relatively simple and quick, analogous to a visit for otitis media or a blood pressure check in primary care. Having a large number of these types of visits enables physicians to make more money, or to spend more time with new patients while remaining financially solvent; however, it diminishes access for new patients with new problems. It raises important questions about whether such promising practices will be adopted without major changes in the way physicians are paid to deliver care.
I congratulate the authors for uncovering some interesting insights about the nature of outpatient specialty care in the US, and hope they will lead to pathways toward increasing appropriate access to specialty care and improving the primary/specialty care interface.
References
(1) McManus M, Fox H, Limb S, Carpinelli A. Promising Approaches for Strengthening the Interface Between Primary and Specialty Pediatric Care. Washington, DC: U.S. Maternal and Child Health Bureau, 2006.
Competing interests: None declared
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Competing Interests: None declared.