The odds that a patient visiting a physician would be referred to another physician – usually a specialist – rose by 94% between 1999 and 2009, while the absolute number of physician visits that resulted in a referral increased 159% during the same time frame, reflecting the rise in overall ambulatory visits during that decade.
The biggest increases were noted in referral rates from primary care physicians for patients with the following types of symptoms: cardiovascular (a referral rate of 8.5% in 1999-2002, increasing to 14.9% in 2006-2009), gastrointestinal (12.3% to 17.7%), orthopedic (12.4% to 16.5%), dermatologic (10.1% to 15.4%), and ear/nose/throat (4.5% to 8.5%), according to a study published Jan. 23 in the Archives of Internal Medicine.
Only physicians with ownership interests in their practices or those who obtained most of their income from managed care contracts had slower growth in referral rates.
The authors analyzed nearly 850,000 ambulatory patient visits in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, focusing on the decade 1999-2009.
It’s not entirely clear why referral rates are rising, according to Dr. Michael L. Barnett and his colleagues from Harvard Medical School, Boston.
"One possibility is that care is becoming increasingly complex, thereby requiring ever more care by specialized physicians," Dr. Barnett said. Evidence for this theory includes the fact that physicians increased referrals for patients with cardiovascular or dermatologic symptoms, but not for those who presented with more general symptoms, such as those associated with viral illnesses.
"Likewise, chief concerns outside the traditional spectrum of primary care, such as ocular or gynecologic/breast symptoms, had a consistently high likelihood of referral from [primary care physicians] but had no significant change in referral rate," they said (Arch. Intern. Med. 2012;172:163-170). "This suggests that some areas, such as cardiovascular and ear/nose/throat symptoms, may be increasingly outside the expertise or clinical portfolio of PCPs [primary care physicians] to manage alone. Other areas, such as gastrointestinal and orthopedic symptoms, had consistently increasing referral rates for PCPs and specialists, which may reflect increasing influence of those specialties in health care markets."
Another possibility is that PCPs simply have too much to accomplish during limited visits, with increasing screening and preventive recommendations, the authors noted.
While appointment duration has not changed significantly in more than 20 years, "patients require more medications and frequently have one or more chronic medical conditions," they said. "As a result... physicians, and in particular PCPs, may not have enough time to address each patient issue, resulting in increased rates of referrals."
Finally, growing numbers of specialists – plus better availability of specialist physicians in many parts of the country – may influence referral rates, the authors said.
It’s not clear whether the increase in referrals overall reflects any kind of an increase in inappropriate referrals, Dr. Barnett said, adding that little literature exists on how to define appropriate referrals. "The complexity of referral appropriateness is compounded by the multiple roles that specialists can play in the care of a patient, ranging from consultative to procedural to co-managing a complex condition."
The increase in referrals between 1999 and 2009 has implications for health care policy and health care spending in the United States, Dr. Barnett and his colleagues noted. "As federal and state policy makers consider policies for reforming the health care system, developing methods to measure referral appropriateness and using these to promote appropriate referrals may be an important strategy for controlling growth in health care spending."
Coordinated Care Requires Payment Reform
Data showing a huge increase in the probability that an ambulatory visit will result in a referral are troubling, according to Dr. Mitchell H. Katz.
The study raises concerns about rising health care costs and fragmented care, Dr. Katz said. "But the real problem is that we have no idea what the data really mean." The increase could stem from more complex caseloads, time-limited primary care appointments, demands from patients, or even malpractice concerns.
Dr. Katz noted that e-referrals, in which primary care physicians and specialists communicate via shared electronic platforms supported by electronic health records, show some promise in helping eliminate costly visits and better coordinate care for patients by ensuring only necessary specialist visits occur.
Still, "for this new vision of patient referral to be fully realized, we will need financing reform," Dr. Katz said. "As long as visits are reimbursed but electronic communication and cognitive time are not, referral visits will only grow. If, instead, payments for groups of patients are bundled, then generalists and specialists can organize their services in the most cost-effective way."
Dr. Katz is director of the Los Angeles County Department of Health Services. These remarks were taken from his editorial accompanying Dr. Barnett’s report (Arch. Intern. Med. 2012;172:100). Dr. Barnett reported no conflicts of interest.
Submitting your vote...
Cardiovascular Disease