April 1996 Bulletin

Managed care upgrades role of generalist

by James J. Hamilton, MD

James J. Hamilton, MD, is Rex L. Diveley professor and chairman, University of Missouri, Kansas City.

The method by which medicine is delivered in the United States is undergoing radical changes. These changes place new and unfamiliar demands upon all medical practitioners. One of the major reform thrusts has been to promote the primary physician's role in managing the entire spectrum of medical care given to a patient. Significant financial pressures have been instigated to shift medical care away from the specialist.

Postgraduate funding for medical education is being decreased. Mandates requiring that 50 percent of graduates be trained as primary physicians have been imposed on medical schools with the loss of governmental support if not complied with. Specialty training slots are being decreased both by governmental dictum and the severe financial pressures being placed on institutions.

How does this affect the role of the specialist? The specialist model of health care delivery has been the standard of medical care in the U.S. for decades. Patients in the U.S. have always had the expectation of the best medical care, regardless of the costs. This has allowed individual practitioners to market an area of expertise. In orthopaedic surgery, subspecialties were developed in the areas of hand surgery, joint replacement, spine surgery, pediatrics, sports medicine, tumor surgery, trauma surgery, foot/ankle surgery and shoulder surgery. Orthopaedic practices were structured to have a practitioner in each subspecialty to allow competition with other groups. Residents chose fellowships based on the subspecialty need in the area where they wished to settle.

Literally 75 to 80 percent of residents take a fellowship to be more attractive in the job market. Having completed an extra year of training in a very narrow area, many fellows then join a practice with the expectation that they can restrict their practice to their area of special training. It soon became apparent that the volume required to maintain a full practice load in a narrow subspecialty field was often unavailable. This caused the practice pattern to drift towards "an interest" in the area of subspecialization and a large amount of work being done outside that area.

Enter medical reform with changes in the delivery of medical care. How will these changes affect the practice of orthopaedic surgery in the U.S.? From my viewpoint as a residency director, the pendulum is swinging rapidly away from subspecialization. I used to receive phone calls from orthopaedic groups looking for someone "interested in backs or hand." Now the callers ask for a "solid all-around person." When I have been unable to provide an individual with a generalist approach, I have been asked for "a sports medicine fellow-they are really only a generalist anyway!"

I have noticed that the referral patterns in my community have begun to significantly change. Before, Dr. A would send his patients needing total joints to Dr. B and Dr. B would send his patients in need of arthroscopy to Dr. A. Now with managed care, if Dr. A is in insurance Plan X and Dr. B is in Plan Y, these referrals are not feasible. Before, when Dr. A sent his patients to Dr. B for a total joint he knew Dr. B would provide an excellent service. Now the physician in Plan X who claims to do total joints does not do as good a job as Dr. A could do himself. So Dr. A is performing total joints again.

Patients also are changing their demands. In the past when they felt they were receiving the best care available, they did not mind going to one practitioner for one problem and another physician for a different problem. In the era of managed care, when the patient's perception is one of being shuffled from pillar to post in an effort to deny them care, multiple practitioners are met with hostility and suspicion. Administratively, the practitioner who can "handle it all" is a lot more attractive to a managed care program. While there will still be a need for a few "super-subspecialists" who handle very unusual and/or difficult cases such as tumor resection and reconstruction,

I believe the majority of orthopaedic care will be handled at the local level even in the HMO. This makes the "generalist" the orthopaedic surgeon of the future.

The orthopaedic surgeon who can provide the fracture care, the knee arthroscopy, the carpal tunnel release, the virgin total joint, and the straight forward laminectomy will be able to handle 90 to 95 percent of everything that is referred to him or her from the gatekeepers and will be prized. A broad-based generalist will decrease the need for narrowly focused subspecialists within the HMO system. Subspecialty care is expensive and will be tightly rationed. For the very unusual problem, a large metropolitan area might have a few "super-subspecialists" who would do "out of program" work for several different HMOs.

What is the role of the generalists? They will be the foundation of the whole system for the provision of musculoskeletal care. They will be the role models of the future. They are the future of orthopaedic surgery.

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