Freedom of choice – always beneficial?

Isabelle Peytremann-Bridevaux and colleagues addressed a question which is very interesting regarding the ongoing discussion among Swiss physicians about managed care [1]. Managed care includes a strong role for the primary care physician; he usually becomes a gate-keeper within the healthcare system. Without his (or her) initiative a referral to a specialist is impossible or at least much more expensive for the patient. Many specialists fear the implementation of such systems, and the initiated referendum against the managed care initiative reflects the divorce regarding this issue among primary care physicians and specialists in Switzerland [2, 3]. But gate – keeper roles also exist without managed care models, as e.g., in the Netherlands or in the National Health Service (NHS) in the United Kingdom. The evidence from various studies and analysis of healthcare-system data is quite obvious: they clearly show that healthcare systems with a strong position of the primary care physician also reflected in a gate – keeper role are associated with lower overall health care expenditures [4]. Cost reductions can be tremendous as a study by Forrest et al. indicated: first contact care with a primary care physician led to reductions in ambulatory episode-of-care expenditures of over 50% [5]. Furthermore, primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations [6]. Starfield et al. could show that a higher amount of primary care physicians led to increased life expectancy but a higher amount of specialists did not result in a higher life expectancy. As explanation the authors concluded “Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality” [7]. The obvious finding that primary care physicians are able to increase appropriate specialist use is a convincing argument for their gate – keeper role.

This is opposite to the people’s will, at least according to the results of Peytremann-Bridevaux. They report in their survey that 45% of participants found it very important to be able to choose the specialist physician they wanted to visit. Consequently, the question arises if managed care models and gate-keepersystems ignore the people’s will.

To approach this question we should take a closer look at the survey. When people are asked “do you want to be free to chose” or “do you want to be limited”, it is quite obvious that most of them opt for the largest extent of freedom of choice. The more important question is: what are they willing to pay for this freedom? Recent figures show that 51% of all Swiss inhabitants already have an insurance model with a limitation in specialist choice [8]. Taking into account the comparable small reduction in the insurance fee, the freedom of choice does not seem to be as important as the survey may indicate. Furthermore, the percentage of people in insurance models with limited choice might be much higher if a large number of patients – estimated 40% of all Swiss inhabitants – would not receive financial support from the community to lower their insurance fees. This support takes away nearly any economic burden to choose a cheaper insurance model which is associated with a limitation in freedom of choice. However, patients are quite right in trusting their primary care physician regarding referral decisions: they are more satisfied with a referral if it was initiated by the PCP instead of choosing the specialist on their own [9].

In conclusion: freedom of choice surely is “nice to have”, the question is: is it always really beneficial for the patient?

References

1 Peytremann-Bridevaux I, Ruffieux C, Burnand B. Freedom of choice of specialist physicians is important to Swiss residents - A cross-sectional study. Swiss Med Wkly. 2011;141:w13315 http://www.smw.ch/content/smw-2011-13315/ .

4 Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy. 2002;60(3):201–18.

5 Forrest CB, Starfield B. The effect of first-contact care with primary care clinicians on ambulatory health care expenditures. J Fam Pract. 1996;43(1):40–8.

6 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502.

7 Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations’ health: assessing the evidence. Health Aff (Millwood). 2005;Suppl Web Exclusives:W5-97-W5-107.

9 Rosemann T, Wensing M, Rueter G, Szecsenyi J. Referrals from general practice to consultants in Germany: if the GP is the initiator, patients’ experiences are more positive. BMC Health Serv Res. 2006;6:5.

Notes

Funding / potential competing interests: No financial support and no other potential conflict of interest relevant to this article was reported.