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Neurology 1996;46:276-277
The role of specialist care in the emerging managed health delivery system is changing. Most health maintenance organizations (HMOs) are limiting access to specialists because of concerns about cost. Despite the need to control spending, there is optimism that specialists can "prove their worth," presumably by providing a much better outcome even if it means a higher price. To convince payers not to skimp on specialty care, however, we need more data on qualitative improvements in care provided by specialist consultants. [1] Specialists will need to prove their usefulness to generalists acting as gatekeepers of the health delivery system. Can this be done?
To evaluate the impact of specialist contributions to inpatient management, we assessed the usefulness of neurologic consultations in a university setting for 5 months in 1994. We arbitrarily defined a consultation as useful if it met one of the following criteria: (1) The neurologist's differential diagnosis contained a diagnosis (whether ultimately correct or not) that had not been included by the referring physician. (2) The neurologist suggested even a single procedure not previously ordered by the primary physician that was ultimately useful in making the correct diagnosis or eliminating other alternative diagnoses. The procedure must have been done. (3) The neurologist suggested a treatment regimen that was carried out by the referring physician and was different from the regimen proposed by the primary physician prior to the consultation. If no treatment regimen had been proposed by the referring physician, the consultation was considered useful. (4) We elected to consider a consultation as not useful if it only confirmed the primary physician's differential diagnosis or management. We …
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