When It Comes to Costs of Care, Family Physicians Provide Added Value, Study Finds

Family physicians are a cost-effective usual source of care, especially when compared with subspecialists or even internists, according to a study conducted by the AAFP's Robert Graham Center and published in the March/April issue of Health Affairs.

The study, which used Medical Expenditure Panel Survey data from 2001-04, looked at health care costs based on who people cited as their physician. It then determined differences between primary care physicians and subspecialists and between physicians in different primary care specialties.

The study found that the cost when a subspecialist served as a patient's usual source of care was $1,430 higher on average per year than the cost of having a family physician as a usual source of care. The study also found -- unexpectedly -- that total health care costs for adults who used a general internist as their usual source of care were $1,201 higher on average than for patients who named a family physician as their usual source of care.

"I thought we would find that primary care was different than subspecialty care as a usual source of care," said Robert Phillips, M.D., director of the Graham Center. "I didn't expect to find that internists would look different, and, in fact, so different that they look like subspecialists -- that was quite surprising."

As a rule, subspecialists practice in more expensive environments and use a different concept of epidemiology than family physicians, which may account for the cost differences between the two groups, said Phillips. However, he added, general internists should be practicing in similar settings and using an epidemiologic perspective similar to that of FPs, which should make the costs between the two specialties comparable.

One potential explanation for the difference in costs between internists and FPs, said Phillips, is that general internists are trained primarily in acute care or inpatient settings, not in primary care settings.

"Prior studies suggest that general internal medicine is trained to a more subspecialty orientation and more procedure-based style of care," Phillips said. "We desperately need payment and training reforms that enable more general internal medicine physicians to function as the primary care physicians they were meant to be."

General internists also tend to locate in higher-cost areas than family physicians, often practicing in areas where subspecialists practice, which could explain why their costs are higher, said Phillips. "We don't know if their costs are higher because they are in a more expensive place or if the place is more expensive because that is where they locate," he said.

According to the study, adult per-patient spending on office-based services at general internal medicine offices was $247 higher on average than spending on office-based services for FPs. In addition, the adult per-patient cost of a visit to a subspecialist's office was $226 higher on average than the per-patient cost of a visit to an FP's office.

In the area of prescription drug costs, adult patients who used general internists as their usual source of care spent $409 more on prescription drugs than patients who relied on FPs as their usual source of care. Additionally, adult patients who accessed care from subspecialists on a regular basis spent $206 more on prescription drugs than patients who saw FPs on an ongoing basis.

The study also found that children with a family physician as their usual source of care had lower annual costs than those with subspecialists or even pediatricians as a usual source of care. The annual cost for children who relied on FPs as their usual source of care was $751 on average per year, per child, compared with $858 for pediatricians and $1,561 for subspecialists.

Annual costs for family physicians and pediatricians were similar, noted Phillips. "Part of this may be explained by pediatricians taking care of younger kids than family physicians," he said. "We controlled for age, but you may not be able to control for all things that are affected by age."

Spending on office-based care averaged $177 a year for a child who relied on an FP as his or her usual source of care, compared with $228 for a pediatrician and $334 for a subspecialist. Similarly, the annual prescription drug cost for a child who used an FP for ongoing care averaged $106 per year, compared with $134 for a pediatrician and $332 for a subspecialist.

Interestingly, survey respondents who cited an office or clinic as their usual source of care instead of a specific provider had lower annual costs across the entire spectrum than those seen for family physicians, general internists, subspecialists and pediatricians. In most cases, community health centers were the offices or clinics cited as the usual source of care, Phillips said.

"Community health centers are a less expensive place to receive care," he added. "We know that family physicians provide most of the physician staffing in those places; it is family physicians operating in a different model."

The survey also indicates that patients and children who did not have a usual source of care had the lowest health care costs because they did not access care on a regular basis and, therefore, did not incur as many costs during the years covered by the study. But without ongoing care, care for those patients is likely to be more expensive later, according to Phillips.