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Physician Referral Patterns Ripe for Scrutiny

Cheryl Clark, for HealthLeaders Media, January 26, 2012

When is a general practitioner's referral of a patient to a specialist an appropriate one that will likely lead to better outcomes, and when is it a categorical waste of money? Even worse, when is it something that provokes an unnecessarily harmful intervention involving more radiation, more specialists, false positives, or even useless surgery?

And on the flip side, when is a referral that would be appropriate denied because it conflicts with a primary care physician's pecuniary interests?

These questions surround the latest quality issue emerging from the dramatic increase in referrals to specialists, highlighted this week by Harvard Medical School researchers. In a study, they pose even more questions about whether and when a generalist should recommend a patient see another doctor.

The report, by Michael Barnett, MD, Zirui Song, and Bruce Landon, MD, and published in the Archives of Internal Medicine, looks at a sample of data from nearly one million ambulatory visits to primary care providers collected by two respected surveys. They found the number of referrals to a specialist doubled from 1999 to 2009, while during the decade before, rates were stable.

"That fact alone has significant implications for the cost of care and care patterns, because the referral isn't a single visit to a specialist," Landon explains in an interview this week. "It potentially opens up a whole cascade of testing and treatments and hospitalizations and procedures, and additional referrals.

"Understanding more about the nature of these referrals, and their appropriateness and the drivers of these changing patterns, is going to be important as we tackle the cost problem going forward," he said.

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2 comments on "Physician Referral Patterns Ripe for Scrutiny"


Carri D (1/30/2012 at 10:45 AM)
The CMS changes that occurred in 2011 were radical and strongly enforced. I worked in an university oncology setting that bordered other states. Patients would frequently transfer to our facility for more complex treatments..If referrals for home health PT/OT were needed, our doctors orders were no longer accepted. Regulations stated all orders must be written by a MD from patients state. I understand the logic, but explain that to a patient who depends on you for quality care and a doctor who has been writing these orders for decades. The paperwork took away from the quality of care the patients deserved. Shameful Don't get me started on the HUGE cuts in "units" ie medications for terminally ill patients. Beyond shameful. After three days of battling with an insurance company over pain meds. Being told the patient would have to wait 2 wks for a refill. Oxycontin tabs went from 30 for 30 day cycle to 12! In despair I asked if this is when we start taking people out back and shooting them to end their pain and suffering. My patient got her medications. I lost my job.

Gus Geraci, MD (1/27/2012 at 4:54 PM)
The answer is: All of the above! Sometimes it is a waste of money and sometimes it is critically necessary to provide better care. The problem is there is no simple analysis of the why, because it is an interplay of the patient's needs, the patients' demands, the physician's skill and comfort, busy-ness, and reimbursement and other factors. Adjusting reimbursement for outcomes and quality will help.