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Health Care Costs and Financing

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Financial consequences for doctor referrals to specialists affect patient satisfaction but not outcomes

Adults whose primary care physicians (PCPs) were subject to a financial withhold for referrals to specialists were less likely to be referred to a physician specialist, more likely to see a specialist without a referral, and more likely to rate their PCP's care less favorably than patients of PCPs who did not have a financial withhold. However, the presence of a financial withhold generally was not associated with overall reduced access to specialists for these patients, since many of them apparently self-referred, and both groups of patients had similar outcomes, concludes a study supported by the Agency for Healthcare Research and Quality (HS06833).

David E. Grembowski, Ph.D., of the University of Washington, and his colleagues administered a questionnaire to 2,275 adults (most were middle-class whites) prior to an initial visit for pain to one of 261 PCPs in 72 offices in Seattle; followup questionnaires were administered 1 and 6 months later to study the patients' access to specialists, care satisfaction, and health outcomes (for example, severity of pain and functional status). The researchers also administered questionnaires to the PCPs and their office managers to compile an office managed care index (0 for least to 100 for most managed). The index included referral preauthorization requirements, financial incentives, and use of referral or clinical guidelines for specific conditions.

If a PCP had a financial withhold, a patient was 29 percent less likely to be referred to a specialist physician for pain (odds ratio, OR 0.71) and 38 percent more likely to see a specialist without referral (OR 1.38) than patients whose physicians did not have a financial withhold. However, after controlling for both patient factors and other managed care factors, the two odds ratios were similar and no longer significant. Controlling for patient and managed care factors, a financial withhold for referral was associated with a .20 decrease in patient ratings of the care provided by their primary physicians. On average, most patients improved, with less bothersome pain and less restricted activity days, but the managed care factors were not associated with these outcomes.

More details are in "Managed care, access to specialists, and outcomes among primary care patients with pain," by Dr. Grembowski, Diane Martin, Ph.D., Paula Diehr, Ph.D., and others, in the February 2003 Health Services Research 38(1), pp. 1-19.

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