Demand may be heating up for specialists, if certain industry signposts are right.
And some solo practitioners are being swept along with the tide.
In the past, gatekeepers for managed-care plans often steered patients away from specialist physicians. But now, doctors' groups, HMOs and hospitals are turning up the heat on recruiters, urging them to search for specialists, too.
While some healthcare consultants have noticed the trend, they agree it's still a bit early to state definitively what the shifting numbers mean.
Some say the development demonstrates pent-up demand for specialists and solo practitioners. Others say it may just show that doctors' groups, HMOs and hospitals are getting choosier about the providers they pick.
Ironically, the industry consensus a few years ago was that there was an oversupply of specialists--70% of practicing doctors are specialists; 30% are generalists. Experts said the numbers foreshadowed a shortage of opportunities for specialists, and that the percentages needed to be reversed--or at the least, even.
But a recent survey of 1,664 search assignments by the physician recruitment firm Merritt, Hawkins & Associates of Irving, Texas, reveals that searches for specialty doctors grew 51% in the year that ended April 15, while searches for primary-care doctors grew by only 12%.
Oncologists, psychiatrists and cardiologists were the most sought after specialists, according to the survey.
Searches for solo practitioners increased by 5%.
A number of forces are driving the demand for specialists, says Joe Smith, a vice president at Merritt, Hawkins. "There has been an emphasis on integrated healthcare delivery systems, a demand to round out managed-care plans (by adding specialists)," he says. In addition, a buyer's market has put pressure on health plans to offer consumers more choice, and legislative efforts by a number of states have sought to prevent managed-care plans from blocking access to specialists, a trend driven by consumer backlash.
Paige Jackson, a managed-care consultant in Houston, Texas, has seen the same phenomenon.
"The best-selling insurance product in the market does not require gatekeepers," she says, "which has led to a movement among payers toward working out partnerships with specialty groups and selling open access (health plan) models." The result, Jackson says, is that business is up for obstetrician-gynecologist groups and orthopedics groups, and they are adding physicians to meet the demand.
Smith says the increased savvy of the specialists when it comes to managed care also is driving up demand. Specialists have figured out how they can be valuable to managed care and make money at the same time.
Doctors in many multispecialty and single-specialty groups are not only accepting capitation, but also serving as a new sort of gatekeeper--one who sees patients face to face and has the expertise to judge where they will get the most appropriate treatment. When warranted, a patient's direct visit to a specialist will save money, specialists say, because the trip to a primary-care physician is bypassed.
Among the other explanations for the rising demand for specialists is the number of older doctors who are leaving the field and the aging of baby boomers, Smith says.
"As we as a population continue to age, specialists become important. Older folks have multiple illnesses that are treated by specialists," he says.
Mark Smith, who is also a vice president at Merritt, Hawkins (and no relation to Joe Smith), says that many hospital clients of the firm have had to go outside their communities to recruit specialists, which has served to push up demand. As has the increased pickiness of his clients.
Current requirements "start with name-brand training, board certification, a desire for the doctor 'to be westernized,' meaning American-born or at least trained in a U.S. medical school," he says.
"There is a growing realization that specialists can really affect the cost of medicine," says Breaux Castleman, president and financial operations officer at Scripps Clinic in San Diego. One reason: the well-known statistic that 20% of patients--those who have serious or chronic illnesses and who are generally seeing specialists--account for 80% of medical costs.
Mark Smith also attributes the increased opportunities for specialists to the cyclical nature of supply and demand. There was a huge surge in the last four years in the demand for primary-care doctors, he says. Now the demand for specialists-and for specialists in solo practice-is heating up. "The emerging opportunities for solo practitioners is surprising to everyone," Castleman says. "The power of independent practice associations is much greater than anyone had previously thought."
At least part of that power comes from physicians using the Internet to link to other solo practitioners in IPAs. Working together on-line allows them to share information in clinical and financial databases, and gives them broader geographic coverage, mimicking the advantages of multispecialty groups or larger group practices.
"They can have the same functionality as a large multispecialty physicians' group, which means they are formidable competition," Castleman says.
As for Scripps, Castleman says it adds an equal number of specialists and primary-care physicians to its staff every year-about five of each--to replace physicians who retire or leave to pursue other opportunities. The clinic has 124 primary-care doctors and 160 specialists. This year it added a new type of specialist: a general surgeon who specializes in liver transplants.
Like a number of consultants, Bill DeMarco, a managed care consultant in Rockford, Ill., says the rising demand for specialists is the result of an effort to provide more consumer choice.
"The issue here is access," DeMarco says. "Specialists fought and fought capitation; now it's easier than they ever dreamed. They see the grand scheme of putting specialists in rural communities and of being the only game in town."
In Washington, Randolph Fenninger, executive vice president of Marc Associates, says demand has remained steady for certain specialists, such as urologists and gastroenterologists.
"We're seeing an increase in growth in point-of-service plans, which makes it easier for specialists to do business," he says.
In general, Fenninger sees a near ultimatum from employees in large companies that they not have to deal with gatekeeper doctors. The aging of the population increases the demand for specialists' care," he says. "More people are needing urology, cancer and heart care."
There are those, however, who doubt that the demand for specialists will edge primary-care physicians out of the picture. "There is still a huge demand for primary care physicians," says Geoff Staub, director of marketing for Cejka & Co., in St. Louis, Mo. "It's just not as acute as it was three years ago. And there are still too many specialists."
In fact, specialists outnumber primary-care physicians by almost two to one, according to a 1997 survey by the Medical Group Management Association in Englewood, Colo. Lisa Pieper, project manager at MGMA, says the group's survey of compensation at 1,581 physician group practices found that of 27,723 doctors, 16,728 were specialists and 10,985 were primary-care physicians.
Douglas McKell, president of Physician Strategies 2000, a physician practice management and consulting firm in Franklin, Ohio, says his firm has seen greater demand for "very good specialists" only.
The bottom 35% is difficult to place, he says. As physician groups' incomes are being squeezed by managed care, they are getting more choosy about the specialists they recruit, McKell says.
"It's costly to bring someone in and costly to get rid of them if it doesn't work out."
Regardless of the real measure of the demand for specialists--whether it's a substantial trend or merely a temporary blip on the radar screen--DeMarco says it signals a future move by managed care to extend its reach into new geographical areas.
Debra Beachy is a Houston-based freelance writer who specializes in business topics.