Managing the interface between primary care provider and specialist in the era of open access

Open access health plans are demonstrating the fastest growing enrollment in the marketplace. Managed care organizations are shifting away from the gatekeeper model of cost containment toward other methods such as provider profiling for resource consumption and capitation of specialists. With reduced demand for services, many specialists are competing with primary care physicians for patients. Confusion abounds regarding what constitutes a minimum standard of primary care management and when it is appropriate to refer. Regardless of the cost-containment methods used, financial incentives applied in the absence of clinical appropriateness criteria may result in implicit rationing of health care. Software embedded clinical criteria are essential to measure clinical performance, maintain provider skill, enable appropriate clinical decisions, and support efficient division of labor among generalists and specialists.