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Primary care physician referral rates are a physician-driven behavior

Excessive referrals to specialists by primary care physicians (PCPs) may result in unnecessary tests, procedures, and costs. On the other hand, under-referral may result in health problems and additional costs that could have been avoided by appropriate specialty care.

PCP referral rates are mostly driven by the physician, concludes a study supported by the Agency for Health Care Policy and Research (HS09397). It found that referral rates and variations in referral rates of PCPs in a large managed care organization (MCO) remained very stable over time and for various diagnoses, even after adjusting for differences in patient case mix.

Peter Franks, M.D., and his colleagues from the University of Rochester analyzed the medical claims database of the largest local MCO in Rochester, NY. The MCO employed an independent practice association (IPA) model, in which neither PCPs nor specialists were capitated (paid a certain amount of money per patient or per diagnosis). Each patient was assigned to a PCP, and over 95 percent of local PCPs participated in the IPA. The researchers examined the referral rates for adults 25 years of age and older enrolled in the MCO who visited their PCPs during 1995 and 1996.

About 40 percent of patients are referred each year. In this study, family physicians referred significantly fewer patients than internists, and older physicians made more referrals than younger physicians. The large variations in PCP referral rates (5 percent to over 60 percent) were only minimally affected by patient case mix. The researchers conclude that PCP referral rates largely reflect a physician-driven behavior that is relatively stable over time. These researchers are now looking at the underlying physician factors that drive this behavior and its impact on costs and patient outcomes.

For more details, see "Variations in primary care physician referral rates," by Dr. Franks, Jack Zwanziger, Ph.D., Cathleen Mooney, M.S., and Melony Sorbero, M.S., in the April 1999 Health Services Research 34(1), pp. 323-329.

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