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Physician Referral Patterns Ripe for Scrutiny

Cheryl Clark, for HealthLeaders Media, January 26, 2012

Barrett and Landon suggest two main reasons for the increase. First, care in certain arenas is more complex, demanding more training and experience that only specialists have. For example, Landon points to cardiology or ear, nose and throat symptoms, "where over time there has been the introduction of more treatments, more technology, and more innovation."

The number of visits resulting in a referral to a cardiologist increased from 8.5% to 14.9% and the number resulting in a recommendation to an ENT went from 4.5% to 8.5%.  Orthopedic referrals went from 12.4% to 16.5% and those for dermatology consults went from 10.1% to 15.4%.

But the second reason has to do with what Landon calls "the tyranny of the 15-minute visit." Today, a physician has more guidelines to follow, his or her patients are older and sicker with more co-morbid conditions. "There's only so much a primary care physicians can do in the small time allotted, so they say, 'I'll address problems A and B, but problem C, I'll give that to a specialist.' "Of course, the time the doctor allots is influenced, at least in part, by how much the payer reimburses."

The Harvard study got an edgy reaction in an editorial by Mitchell Katz, MD, who directs health services for the County of Los Angeles and is a practicing internist. Katz’s commentary was headlined, "How Can We Know So Little About Physician Referrals?"

Katz says it's unclear "whether we are currently referring too often, too infrequently or (most likely) both, depending on the patient and the situation." Are patients demanding referrals more "or are we referring more because of concerns of malpractice?" which of course brings up a third reason for referrals.

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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.