"So why do we do this? It's because that's how the specialist gets paid. If the primary care provider calls a cardiologist and says, 'I have Mrs. A, and she's on drug one, two, and three and still short of breath, what would you suggest?' then the specialist does not get paid."
Katz says that one thing he and other health policy officials are trying to do in public systems is "replace visits as the goal with improving the patient's care as the goal. And sometimes that will mean a visit. But sometimes it would mean calling up the specialist and point to an image or an electronic medical record."
Landon says that from published research so far, he can't estimate how many specialty referrals are unnecessary. "It's not a simple answer," he acknowledges. "But that's something we're very interested in learning about in the future."
It appears that learning opportunities are definitely on the horizon.
As practice and referral patterns change with bundled payments, increased hospital employment of physicians, the growth of accountable care organizations and, of course, more transparency with quality data on Physician Compare beginning next year, I can't wait to see what the referral landscape looks like in a few more years.
As Katz says in his editorial, the solution does require financing reform. "If instead, payments for groups of patients are bundled, then generalists and specialists can organize their services in the most cost-effective way."