Hospital-based versus free-standing primary care costs.

A survey of the literature supports the broad generalization that primary care delivered in this hospital outpatient department will be more expensive than care provided in a free-standing setting. Among the reasons discussed by the author are: (1) reimbursement policies of third party insurors which mask and inflate the distribution of the true costs of care within the hospital; (2) lack of control by outpatient department directors over their own costs; (3) the degree to which the availability of sophisticated and expensive technology within the hospital setting encourages its utilization; and (4) the differences in case mix: "sicker" patients are seen in outpatient departments. Gold recognizes that most studies to date contain serious limitations in their generalizability; she concludes that additional studies are necessary to explain why the costs vary to the extent they do. She also suggests studying other issues such as access, consumer preferences, provider preferences and training requirements, and quality of care before reaching any decisions about the future of hospital-based primary care.