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Physician Referral Patterns Ripe for Scrutiny

Cheryl Clark, for HealthLeaders Media, January 26, 2012

"Survival has not doubled in the United States during this [10-year] time. We haven't seen major improvements in health outcomes during that time.... I don't want to give it a number, because there's no data, but as a practicing doctor, I would say a large number of specialty referrals do not in and of themselves lead to benefit."

Those could be fighting words. Katz says that in his experience, often these referrals happen even though the generalist is confident of the diagnosis and could manage the patient with a prescription or advice, but decides to refer to escape legal responsibility or a lawsuit if something about the case goes wrong, he says.

One hint that seems to support some of Katz' view comes in a few lines from the Harvard paper indicating that referral patterns are much more discretionary, a function of economic interests, than most doctors would like to admit.

The increase in referral patterns to specialists was upwardly consistent "across all subgroups examined, except for slower growth among physicians with ownership stakes in their practice or those with the majority of income from managed care contracts," the Harvard researchers wrote.

So doctors refer when they have no financial stake in keeping the patient, and don't when they do?

The authors said this "might reflect a financial incentive for these physicians to keep patients' care within their practice."

Katz expands, saying that he even questions the reason why a referred patient actually has to physically "visit" a specialist. "If the primary care doctor is unsure, why can't that doctor just call the specialist? That would be less expensive for everybody, and more convenient for the patient.

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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.