Primary Care Use by Specialty Clinic Patients at a County Hospital

Brief communication PRIMARY CARE USE BY SPECIALTY CLINIC PATIENTS AT A COUNTY HOSPITAL Many administrators of public sector health systems, facing the financial and organizational challenges posed by managed care, are seeking to maximize the cost-efficiency and quality of their service systems.1 Most states have now initiated Medicaid managed care programs, in which county health systems or private health maintenance organizations (HMOs) contract with states to provide health services to designated Medicaid populations on a capitated payment basis. Twenty-three states now plan to implement such programs statewide,2 and most have designed their programs to engender competition among county health systems and other organizations bidding for state contracts. In preparation for the challenges of a more competitive environment, many health planners are considering expansion of the primary care resources of county health departments.3,4 In the outpatient setting, primary care physicians are more likely than specialists to provide ongoing and comprehensive care, and these attributes have been associated with improved outcomes for many conditions, reduced rates of hospitalization, and improved patient satisfaction.5"9 In San Francisco County, the Department of Public Health (DPH) is implementing its own Medicaid managed care program, one of 13 pilot counties in California's new Medicaid Managed Care Program. While the San Francisco DPH was formerly the primary provider of health services to low-income and uninsured residents of San Francisco County, it will soon compete with a private sector managed care plan for future state contracts. In preparation, the DPH has proposed the widespread implementation of a primary care-centered managed care system that would serve all of its patients.10 Similar long-term goals have been set by other county health departments entering managed care contracts.3 The San Francisco DPH has yet to determine the organizational structure of its system of care, but the expanded role of primary care physicians may include the coordination and approval of patients' use of specialty services. Currently, 18 clinics in San Francisco County offer primary care services to low-income or uninsured residents, including both DPH-operated and independent not-for-profit clinics. The San Francisco DPH currently operates three hospital-based (at San Francisco General Hospital) and eight communitybased primary care clinics, which were the sites of approximately 240,000 adult Journal of Health Care for the Poor and Underserved · Vol. 9, No. 1 · 1998 6 Primary Care Use by Specialty Clinic Patients patient visits by 50,000 individuals in 1992. Meanwhile, seven not-for-profit community health centers were the sites of 230,000 patient visits in 1992. Despite current primary care resources, many users of county health services perceive barriers to accessing primary care services.11 A number of users (proportion unknown) have not been linked with primary care services; instead, they rely exclusively on specialty clinics at San Francisco General Hospital (SFGH) for their regular care. Such patients might receive high-quality care at a lower cost if they could be linked with primary care physicians. In the following case study of the San Francisco County DPH, the number of regular users of county specialty clinics lacking concurrent primary care is estimated, and the implications of these estimates are discussed in the context of the DPH's current preparations for future state managed care contracts. The results of this case study may inform health planners elsewhere in their attempts to adapt similar delivery systems to the financial and organizational challenges of managed care. Methods A retrospective analysis of DPH patient records was conducted to estimate the percentage of adult patients seen regularly at SFGH specialty clinics who lack a primary care provider. The primary care status of regular specialty clinic patients was identified using computerized administrative data and subsequent hospital chart review. Search of computerized records. The SFGH registration database was searched for all patients older than 18 years of age seen regularly at medical or surgical specialty clinics in 1993. The following clinics were classified as "medical specialty clinics": cardiology, dermatology, endocrinology, gastroenterology , hematology, infectious diseases, neurology, oncology, pulmonology, renal, and rheumatology. The following clinics were classified as "surgical specialty clinics": general surgery, trauma surgery, breast, neurosurgery, otolaryngology , ophthalmology, orthopedic surgery, and urology. Patients with two...