Sunday, January 29, 2012

Something we could learn from changes in referral rates

Michael Barnett and colleagues published an article in the Archives of Internal Medicine that documents a rather large change in the annual rate of referrals to other physicians from physician office visits in the United States. "Trends in Physician Referrals in the United States, 1999-2009" concludes that the probability that an ambulatory visit to a physician resulted in a referral to another physician increased by 94% (from 4.8% to 9.3%) during this period.

The authors are not sure why this happened.  One hypothesis they toss out for future study is that physicians are under pressure for time and therefore refer more. They note that "physicians are increasingly faced with more to do during the typical visit despite no meaningful change in appointment duration in 2 decades."

Whatever the reason, this change in behavior has a direct link to the rising cost of health care in the country.  Specialists who see patients generally charge more than primary care physicians for a visit.  Plus, a visit to a specialist is often likely to lead to a procedure or other intervention, again at an additional cost.  Those specialist visits, in turn, are characterized by a huge variation in practice, providing a prima facie case that the care delivered in those offices is not driven by evidence.

The article provides a hint of some additional research that might shed light on the efficacy of different rate structures in influencing referral patterns.  The authors say, "This trend was 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." 

I'm not sure what the ownership connection might be, but the managed care connection is clear.  Even under a fee-for-service rate structure, insurance companies have enforced certain referral standards over the years, and doctors seeing those patients would probably be sensitized to the desires of those payers to avoid higher cost referrals.

Here's the hypothesis I'd like the authors to test:  Would we see a difference in referral rates if we were to look at patients who are covered by capitated, or global, contracts compared to those covered by fee-for-service contracts?  Given the dearth of information published so far about capitation -- and given the religious fervor evidenced by some proponents and their propensity to avoid transparency about results -- wouldn't it be good to see if it makes a difference?  Some kind of objective test would be valuable.


Anonymous said...

I'm going to put my money on this being predominantly a PPO phenomena and not seen as much with managed care contracts, and further wager that it is higher outside of small practices.

Here's the reasoning: out here in CA large companies like Sutter are gobbling up smaller practices and clinics. If a patient has a PPO then turning one visit into multiple visits (via referral) all the money stays in-house since the referral will be to another doctor under the corporate umbrella. Since doctors get paid a share of the profits...

Brad F said...

Even in areas with greater ratios of primary care to specialists (and presumably less referrals due to the math and panel size), mitigating cost is complex and hard to untangle. If I had to bet, if you looked more deeply, the association between referrals and utilization would be highly variable, and not one that would repair with a top down fix.


Keith said...

If you look at this strictly from a viewpoint of what generates the most revenue for a health care system, then it makes sense to structure things so that your primary care docs do not have the time to perform an adequate job, and are encouraged to refer up the food chain. The specialist canthen garner a larger profit margin.

PCPs that are self employed may also be under less constraints as to the number of patients they need to see as well as the time frames of appointments. Also, as systems become larger with staff and PCPs that are not as familiar with the patient, you may also encounter more situations where there is not appropriate time booked for the patient. My staff knows of those patients that are more complicated and likely to take more time and books extra time accordingly.

It all depends on whether your trying to build a cost efficient health care system or one that churns out income. Unfortunatly, most seem more interested in the income stream which is why our health care system has tilted so heavily toward high tech specialty care as opposed to most other world wide health care systems with a single payer interested in constraining cost; or at least getting quality for its money.

Marco Huesch said...

This from HSR's special payment reform issue last month
might be relevant: "[Primary care][P]hysicians in highly capitated practices had the lowest total costs and intensity of care, suggesting that these physicians develop an overall approach to care that also applies to their FFS patients."