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.
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.
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.
"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.
"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."