Specialty Care

Many studies comparing specialists and primary care physicians in fee-for-service settings have found that specialists treat conditions within their areas of expertise more intensively than primary care doctors. Despite concerns that specialists may be more likely than primary care physicians to provide costly and unnecessary care, studies have shown that for some conditions, including heart attacks and severe asthma, patients treated by specialists are more likely to receive appropriate care and follow prescribed treatment regimens than patients treated by other physicians. Less is known about differences in treatment patterns between patients cared for by specialists and other physicians in health maintenance organizations (HMO). Specialist care is generally more expensive than care provided by other physicians, and some studies have found that the proportion of appointments with specialists is smaller for HMO patients than for those with private fee-for-service insurance. This report examines potential differences in treatment patterns for HMO patients treated by specialists and those treated by generalist physicians. Specifically, GAO assesses follow-up treatment for heart attack survivors enrolled in Medicare HMOs. GAO chose this group because the differences in the quality of cardiac care provided by cardiologists and generalists have been particularly well-documented and the effectiveness of specific treatments for coronary heart diseases has been clearly shown.

GAO noted that: (1) the ongoing use of cholesterol-lowering drugs and beta-blockers reported by Medicare heart attack survivors enrolled in HMOs generally parallels the patterns for heart attack survivors in the U.S. health care system overall; (2) as others have found for the general patient population, GAO found a much smaller proportion of respondents reported taking cholesterol-lowering drugs (36 percent) or beta-blockers (40 percent) than would be expected if everyone who would benefit from using these drugs were taking them; (3) Medicare HMO heart attack survivors with regular cardiology care--40 percent of GAO's survey respondents--were more likely to take the recommended drugs than those without regular appointments with a cardiologist; (4) enrollees who saw cardiologists regularly for their cardiac care were approximately 50 percent more likely to take cholesterol-lowering drugs and beta-blockers--a finding consistent with other comparisons of care provided by cardiologists and generalists; (5) although factors such as age, education, self-reported health status, and the presence of other illnesses also influenced who took cholesterol-lowering drugs and beta-blockers, they did not account for the higher use levels observed among patients who had routine cardiology appointments; (6) still, even patients of cardiologists often did not take one or both of these drugs; (7) by contrast, the overall use of aspirin was much higher--71 percent--and while regular patients of cardiologists were still more likely to take aspirin, the difference between them and other patients was smaller and not statistically significant (75 percent versus 68 percent); (8) on the whole, GAO's results for heart attack survivors treated by cardiologists and generalist physicians in Medicare HMOs are consistent with those of other studies of physician specialty differences in the United States; and (9) GAO's finding that patients under the regular care of cardiologists are more likely to take recommended medications reinforces the findings of the small number of other studies of physician specialty differences that are specifically concerned with HMO members and extends those findings to an older population and to a different medical condition.