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Patients value primary care physician for source of care   Patients value the first-contact and coordinating role of primary care physicians.  However, managed care policies that emphasize primary care physicians as gatekeepers impeding  access to specialists undermine patients’ trust and confidence in their primary care physicians, according to a recent article in an issue of The Journal of the American Medical Association (JAMA). Kevin Grumbach, M.D., from University of California at San Francisco, and colleagues studied  7,718 patient responses to a survey mailed to a cross section of managed care plan members who received care from 10 large physician groups in California to assess patient attitudes toward the involvement of primary care physicians in access to specialty care. “Patients overwhelmingly endorsed the importance of having identified primary care physicians  to integrate their overall care and preferred to involve their primary care physicians in decisions  about obtaining care from specialists,” the researchers write.  “Most patients also preferred to initiate care for new medical problems with their primary care physicians rather than seeking care directly from specialists. These responses indicate that patients perceive a beneficial role for primary care physicians in coordinating their care, suggesting that most patients do not generally endorse a model of fragmented specialty care without primary care physicians integrating this care.” “Our study provides new insights into patient attitudes toward primary care and access to specialty care,” write the authors. “Although patients value the first-contact and coordinating role of primary care physicians, managed care policies that emphasize primary care physicians as gatekeepers impeding access to specialists undermine patients’ trust and confidence in their primary care physicians.” The researchers’ objectives were to determine the extent to which patients valued the role of their primary care physicians as first-contact providers and coordinators of referral services, whether patients perceive that their primary care physicians impede access to specialists and whether problems in gaining access to specialty care were associated with a reduction in patients’ trust and confidence in their primary care physicians. The authors report: 94 percent of patients value having a primary care physician as a source of first-contact care.  89 percent value the role of primary care physicians in coordinating referrals. 75 to 91 percent of patients preferred to seek initial care from their primary care physicians rather than a specialist. 23 percent reported experiencing interference from their primary care physician or medical group when patients desired specialty care. Patients who had difficulties obtaining referrals were 2.7 times more likely to report low trust, 2.2 times more likely to report low confidence and 3.3 times more likely to report low satisfaction with their primary care physicians than patients who said they did not need referrals.   The researchers found that patients want to be able to see a specialist when the patient believes specialty care is necessary. Most patients had experienced difficulties obtaining referrals they believed necessary. Perceptions of referral barriers were one of the strongest predictors of patients giving their primary care physicians low trust, confidence and satisfaction ratings.  The authors contend that high-quality primary care is the foundation of effective and efficient health care systems. They note that managed care in the United States tends to emphasize the primary care physician in the roles of first-contact care and as gatekeepers to specialty care.   They suggest that in the United States, the role of gatekeeper is especially contentious because of the use of economic incentives that may financially reward primary care physicians for thrifty use of referral and hospital services, according to the researchers. “Resolving the gatekeeper conundrum also will require addressing many of the underlying structural problems in the U.S. health care system, such as an overabundant supply of specialists, that contribute to this predicament,” observe the authors. “The challenge in the United States is to create practice arrangements that promote a first-contact and coordinating role for primary care physicians without simultaneously casting the primary care physician in the role of rationer of specialty care,” the researchers conclude.