More Balance between Primary-Care and Specialist Physicians Could Improve U.S. Health

Communities with more primary-care physicians have lower mortality rates, according to an analysis by researchers from the Johns Hopkins Bloomberg School of Public Health and New York University. The researchers also found that having more specialty-care physicians in a community did not have the same positive impact on health and that increasing the number of specialists would not improve the health status of the U.S. population when compared to other industrialized countries. The study is published as a Web exclusive on Health Affairs’ website March 15, 2005.

 “Decisions about the physician supply should be made on the basis of evidence for their utility in improving health and reducing ill health and deaths. Currently, the United States has many more specialists than do other comparable countries with better health levels,” said Barbara Starfield, MD, MPH, lead author of the study and a University Distinguished Service Professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.

The study authors reviewed mortality data from 1996-2000 for 3,075 U.S. counties, which make up 99.9 percent of all U.S. counties. The researchers found that having a higher specialist-to-population ratio did not decrease mortality rates. They also determined that too many specialists would negatively impact communities because more patients would be seen by specialists and would be more likely to receive unnecessary tests and procedures.

The researchers report that, in the United States, the boundaries between the roles of specialists and primary-care physicians are blurred. In countries other than the U.S., specialists typically work in hospitals and see patients only on referral from primary-care physicians, so that the roles are clearly delineated. In the U.S., however, specialists may treat patients for ailments outside their area of expertise, thus putting patients at a higher risk of death. In addition, more specialists decrease the number of procedures performed per physician, which further increases risks of complications or mortality.

“Having too many physicians leads to unnecessary care and runs the risk of greater adverse effects. Simply training more specialists is unlikely to improve health, and will greatly increase costs. The challenge for the United States health services system is to find better ways for primary care and specialist physicians to work together so that health services are more effective, efficient and equitable,” said Dr. Starfield.

“The Effects of Specialist Supply on Populations’ Health: Assessing the Evidence” was supported by a grant from the Bureau of Primary Health Care, Health Resources and Services Administration at the U.S. Department of Health and Human Services.

The study was coauthored by Barbara Starfield, Lelyu Shi, Atul Grover and James Macinko.