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Managed care organizations often face harsh criticism for their use of primary care physicians (PCPs) as gatekeepers to control access to specialists as a mechanism to hold down costs. However, a new study shows that the rate at which PCPs refer patients to specialists has little impact on patient cost or outcomes and efforts to constrain PCP referrals to specialists may be misguided and unnecessary.
Researchers analyzed 1995 claims data and patient survey data to examine the relationships between PCP referral rates and patient costs, health status, risk of avoidable hospitalization, and care satisfaction. The data set included 457 PCPs in an independent practice association and 217,606 adult patients. The survey included 50 patients each from 100 PCPs in 1997.
Unlike similar studies that showed higher costs related to referrals, this study adjusted for differences in patient mix. After adjustment for age, sex, and health status, researchers found no significant relationship between PCP referral rate and costs or patient risk of avoidable hospitalization. The survey data revealed no relationship between the PCP referral rate and patient self-rated physical or mental health. However, patients of physicians with higher referral rates were slightly more satisfied with their care than were patients of physicians with lower referral rates. In addition, referral rate by itself was not an important determinant of patient outcomes.
Researchers concluded that although these results should not suggest that open access to specialists would be cost-neutral, they do support efforts to reduce referrals to specialists by PCPs. The researchers add that containment strategies that restrict referrals to specialists set the stage for competition among specialists and PCPs that may have negative effects.
[See: Franks P, Mooney C, Sorbero M. Physician referral rates: Style without much substance? Medical Care 2000; 38(8):836-846.]