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Physician Referral Patterns Ripe for Scrutiny

Cheryl Clark, for HealthLeaders Media, January 26, 2012

When I spoke with him this week, the pitch of Katz' voice conveyed his astonishment, or at least his umbrage. "The thing I was most struck by is this," he told me. "Here's this major increase in the number of specialty referrals. But there's no consensus on guidelines on who should go to a specialist. Like any intervention, we should know, okay, what are the indications for sending someone to see, say, a pulmonologist?

"It turns out we don't have any indications. I thought that was really surprising because we spend a huge amount of American dollars on specialty care," says Katz, former public health director for the County of San Francisco and an architect of Healthy San Francisco.

That's unlike most procedures or drugs, or imaging studies, where there are guidelines, he says.

He points out that the U.S. has two specialists for every primary care physician, where in Western Europe, the ratio is reversed.

Then Katz says something bound to be controversial: he believes that "most" primary care physicians' referrals to specialists in the U.S. "are unnecessary."

He says, the fact specialists so outnumber primary care practitioners in this country "is one of the often given reasons—and certainly I believe it—why we have so much higher costs but poorer outcomes than most of Western Europe," he says.

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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.