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.