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Health Care Costs and Financing

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Children in U.S. managed care plans are far more likely to be referred to specialists than children in the United Kingdom

Children in U.S. managed care plans are two to three times as likely to be referred to specialists as their counterparts in the United Kingdom, according to a study supported in part by the Agency for Healthcare Research and Quality (K02 HS00003). The greater supply of specialists and higher expectations for direct access to specialty care in the United States compared with the United Kingdom are likely explanations for these differences in referral rates, explains Christopher Forrest, M.D., Ph.D., of Johns Hopkins University. Dr. Forrest and his colleagues point out that U.S. pediatricians function as both primary care physicians (PCPs) and specialists. Yet, in the United Kingdom, patients must obtain general practitioner (GP) approval for specialty referral, and pediatricians are considered specialists.

The researchers retrospectively compared specialist referrals among 135,092 children in five U.S. managed health plans that used PCPs as gatekeepers (a referral is required from the PCPs to see a specialist) with 221,312 U.K. children who visited GPs. Across the five U.S. plans, 19 to 29 percent of children per year were referred to specialists versus 9 percent of U.K. children. Compared with U.K. children, those in the U.S. plans were about twice as likely to be referred to medical specialists, three times as likely to be referred to surgical specialists, and nearly three times as likely to be referred to psychiatrists.

Although children in the United Kingdom were less likely than U.S. children to be referred for specialty care, the U.K. children suffered from a higher disease burden than their U.S. counterparts, indicating a greater need for health care resources. In a few cases, referrals for U.S. and U.K. children were similar, for example, for dermatitis or eczema or congenital anomalies of the limbs. Referrals for chronic tonsillitis, hearing loss, depression, and attention-deficit disorder were significantly higher in the United Kingdom than in the United States. It still is not clear whether the United States overuses specialists or the United Kingdom underuses them, conclude the researchers.

See "Referral of children to specialists in the United States and the United Kingdom," by Dr. Forrest, Azeem Majeed, M.D., M.R.C.G.P., Jonathan P. Weiner, Dr.P.H., and others, in the March 2003 Archives of Pediatric and Adolescent Medicine 157, pp. 279-285.

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