Health Care Utilization and Self-Treatment by Primary Care Physicians and Specialist Physicians

An Analysis Based on Billing Data From the Thuringian Association of Statutory Health Insurance Physicians

Physicians tend to access healthcare services (especially General Practitioners’ [GP] services) less than non-medical patients even if they need to (1, 2). This can be explained with specific barriers (3, 4, 5), for example:

• Difficulty in accepting the patient role
• Worry about lacking confidentiality among colleagues
• More extensive medical knowledge/expertise
• Undertaking informal consultations
• Frequently practiced self-treatment.

Within the outpatient sector, primary care physicians, more specifically GPs differ from specialist physicians as regards the breadth of their knowledge, the scope of their activity, and their billing options. Comparative studies of the utilization of the healthcare system by GPs and specialists are lacking to date.

This study aims to investigate whether an association exists between the field of activity of physician patients and their utilization of general or specialist medical services, under consideration of sociodemographic, morbidity, and activity related characteristics and of self-treatment.

Methods

We analyzed billing data of contract physicians insured in the Thuringian Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung Thüringen, KVT) who had accessed outpatient medical services on at least one occasion in 2019. In order to measure utilization of GP or specialist services we determined two variables each: for each included person we coded whether at least one respective treatment had been accessed in 2019 (variable at least one case of treatment) and we counted per patient, how often s/he accessed a relevant service in 2019 (variable number of treatment cases per patient). We studied differences between general practitioners and specialist physicians as regards their overall utilization of outpatient services as well as their utilization of GP or specialist services (cases of GP and specialist treatment) (always relative to the rate of persons with at least one case of treatment and the mean number of cases of treatment per person). Furthermore we checked whether these differences varied if

• The effects of age, sex, activity, type of practice, and location of activity are controlled for.
• Cases of self-treatment (LANR utilizer corresponds with LANR treating physician [LANR=9-digit lifelong anonymized physician’s number]. 

We used for our analyses simple/multiple logistic regression (binary target values) or negative binomial regression (metric target values).

Results

1222 physicians (31.4% of the baseline total of outpatient physicians in Thuringia), of whom 616 were GPs, were included in the study. The GPs tended to be female and licensed to practice in single-handed practices and rural regions (Table). Specialist physicians accessed services significantly less frequently—relative to the mean number of cases of treatment per patient—than general practitioners (mean number of cases treated: 7.8 versus 8.9; incidence rate ratio [IRR]=0.88; p=0.002). When differentiated by treatment provided by a GP or a specialist, specialist physicians accessed significantly fewer GP services (at least one case of treatment: 65% versus 94%, odds ratio [OR]=0.12, p<0.001; mean number of cases of treatment: 1.6 versus 3.3; IRR=0.48, p<0.001) and more specialist services (at least one cases of treatment: 93.7% versus 86.2%, OR=2.39, p<0.001; mean number of cases of treatment: 6.0 versus 5.1, IRR=1.17, p=0.002). When sociodemographic and activity related characteristics were taken into account, the differences remained significant. For 58.6% of GPs and 34.8% of specialist physicians, at least one case of self-treatment was documented. The mean number of cases of self-treatment per patient was 1.4 for GPs and 0.8 for specialists. When excluding cases of self-treatment, the differences in utilization between the two groups no longer reached significance. The only exception: the mean number of cases of treatment for GPs without self-treatment was significantly lower for specialists than for GPs (IRR=0.83; p=0.004). The Figure shows the differences with and without self-treatment.

Figure

General outpatient service utilization WITHOUT self-treatment

Table

Patient and activity characteristics of included physician patients

Discussion

The study results show that the utilization of healthcare services by physicians requiring treatment differs between GPs and specialist physicians (independently of sociodemographic, morbidity, and activity related characteristics). The difference is mainly due to the fact that GPs billed for more cases of self-treatment. When considering only cases without self-treatment, utilization differs only for GP services, with a lower number of specialist cases treated by GPs. This confirms the impression that this group utilizes GP services to a lesser extent. In our analysis we were able only to consider self-treatment that was billed as a service. In this context our results show that GPs tend to account for more cases of self-treatment. This may be a function of their broader medical knowledge and wider range of prescribing opportunities. International publications with recommendations for physicians’ health advise against self-treatment and recommend accessing GP services if needed. In this regard the results of the present study indicate a partly divergent behavior among doctors. However, to date no official publications exist in Germany. When interpreting the results it also needs to be borne in mind that the type of documented self-treatment was not specified. Furthermore, no conclusions can be drawn about the consequences of this behavior.

A substantial limitation of the study lies in the fact that for 68.6% of physicians providing outpatient services in the KVT, no conclusions could be drawn because they had private health insurance or had not accessed any outpatient services in 2019. However, for the first time, GPs’ and outpatient specialist physicians’ own utilization of health care services was documented systematically and compared. Further studies beyond the scope of the KVT, including physicians providing inpatient services and physicians with private health insurance, are desirable.

Funding

The research project is funded by the Central Research Institute for Ambulatory Health Care in Germany (Zentralinstitut für die kassenärztliche Versorgung in der Bundesrepublik Deutschland, Zi) as part of the 2016 program to promote health services research.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 11 May 2023, revised version accepted on 27 June 2023.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as:
Schulz S, Meissner F, Wolf F, Freytag A: Health care utilization and self-treatment by primary care physicians and specialist physicians—an analysis based on billing data from the Thuringian Association of Statutory Health Insurance Physician. Dtsch Arztebl Int 2023; 120: 688–9. DOI: 10.3238/arztebl.m2023.0160

References

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