HD24 - An Initial Evaluation of Precedent, Need, Support and Desirability of Including Obstetrician/Gynecologist in Legislative Definitions of Primary Care Provider

Executive Summary:
I. The major questions/issues related to the need of legislative intervention with regard to the inclusion of obstetrician/gynecologist (OB/Gyn) in the definition of "primary care provider" (PCP) are as follows:

• Is this an issue which requires legislation or is it one which is best left to consensus powers within the medical community? Is it best left to negotiation between consumers and providers of the various insurance packages (e.g., Preferred Provider Organizations)?

• Is such a definitional distinction necessary to the safety and welfare of consumers of medical services?

• Is the motivation practitioner oriented, consumer oriented or both?

• Do current trends provide sufficient rationale for inclusion of OB/Gyn practitioners among PCPs?

• Do supporting materials (i.e. study results, etc.) provide sufficient evidence of need?

• Do OB/Gyn practitioners, in large part, support the "generalist" designation? Do they prefer to retain a "specialist" designation only? Do they prefer to acquire the former and maintain both (i.e., to be swingers?)

II. Resources and methods of exploration

Exploration has been made through library research and telephone interviews with individuals on the resource list.

III. Summary of Findings

The primary argument seems to rest in the contention that OB/Gyn practitioners currently serve as PCPs to a large number of women. In other words, women rely on OB/Gyn physicians for common ailments unrelated to either preventive or morbid gynecological matters. A furtherance of the argument seems to be that a large number of women would not receive certain general routine medical interventions (e.g., blood pressure readings) were it not for yearly routine visits to a gynecologist.

Current VA Code does not indicate the type of practitioners which can be designated as and serve as PCPs. This is a matter which is established by the medical community. Typically, Family Practice Physicians, Medical Internists, General Practitioners and Pediatricians are included as PCPs on panels for insurance purposes. In some cases, OB/Gyn practitioners may elect to be included as well. (It is interesting to note that OB/Gyn practitioners may serve on PCP panels as generalists, on OB/Gyn panels as specialists or both.)

There is no apparent convincing support for placing this matter before the legislature.

Although the American Medical Association recognizes this group as PCPs, support among OB/Gyn practitioners seems to range from desire to resistance. (Formal, confidential polling of the constituency would be appropriate.)

Research provides some limited support for the proposal and its underlying contentions.

To a major degree, both Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) currently exclude OB/Gyn practitioners from PCP lists. However, most also provide for yearly "well-woman" gynecological visits which do not require PCP referral. Women can by-pass the PCP for that purpose. Indeed, in some cases, women can choose both a PCP and a gynecologist.

With regard to obstetrics, almost all seem to place the OB/Gyn practitioner in the position of PCP during the gestation period. (Of course there are contract variations due to the individual desires of the consumer groups. However, from a consumer standpoint, sensitivity does seem to exist with regard to women's needs and desires.)

Before further consideration of the legislation of Joint Resolution No. 52 is taken, the following administrative actions are recommended:

1) OB/Gyns licensed in the Commonwealth should be surveyed in a confidential and independent manner so that a consensus can be determined with regard to this issue. Personal interest in providing PCP services should be explored. (Such inquiry should be extended to the total physician constituency if possible.)

2) Evidence which justifies this designation and which outweighs potentially adverse consequences to the health of women and fetuses should be gathered before this issue is pursued. (Current evidence is not convincing.)

3) More formal exploration of relevant practices and trends within the health care industry should be performed.

4) Further, a greater exchange of information and ideas should be facilitated between the provider community and purchasers and insurers of their services with an emphasis on determining the need for access. The Bureau of Insurance, Medical Society of Virginia, and other interested parties should be involved in this exchange. A conference involving affected parties may be beneficial.