Trends in Physician Referrals in the United States, 1999-2009

Abstract

Context Physician referrals play a central role in ambulatory care in the US, yet little is known about national trends in physician referrals over time. Objective To assess changes in the rate of referrals to other physicians from physician office visits in the US, 1999 to 2009. Design, Setting and Participants We analyzed nationally representative cross-sections of ambulatory patient visits in the US using a sample of 845,243 visits from the National Ambulatory Medical Care Surveys 1993–2009, focusing on the decade from 1999 to 2009. Main Outcome Measures Survey-weighted estimates of the total number and percentage of visits resulting in a referral to another physician across several patient and physician characteristics. Results From 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral to another physician increased from 4.83% to 9.29% (p<0.001), a 92% increase. The absolute number of visits resulting in a physician referral increased 159% nationally over this time, from 40.6 million to 105 million. This trend was consistent across all subgroups examined, except for slower growth among physicians with ownership stakes in their practice (p=0.016) or with the majority of income from managed care contracts (p=0.007). Changes in referral rates varied according to the principal symptoms accounting for patients’ visits, with significant increases noted for visits to PCPs with cardiovascular, gastrointestinal, and ear/nose/throat complaints. Conclusion The percentage and absolute number of ambulatory visits resulting in a referral in the US grew substantially from 1999 to 2009. More research is necessary to understand the contribution of rising referral rates to costs of care.

Measuring Comprehensiveness of Primary Care: Challenges and Opportunities

“…[1][2][3][4][5] Comprehensiveness is associated with numerous benefits, 1,[5][6][7][8][9][10][11][12] yet several studies suggest it is declining in the U.S. and Canada . [13][14][15][16][17] Here, we discuss the rationale for measuring comprehensiveness in primary care, enumerate the challenges, including available data sources, then describe approaches to measuring comprehensiveness and suggest areas for future research.…”

Challenges in Referral Communication Between VHA Primary Care and Specialty Care

“…4,5 This problem is of increasing concern, as there have been recent national trends towards proportionally more primary care visits resulting in referrals to specialty care. 11 Optimal communication between primary and specialty providers is essential for realizing the goals of the patient-centered medical home (PCMH) care model, an increasingly dominant paradigm in primary care throughout the country. 12 Integrated delivery systems and shared electronic medical records (EMRs) can facilitate communication between primary and specialty care providers.…”

eReferral — A New Model for Integrated Care

“…The specialist reviewer uses the system of the patient-physician relationship, the more optimistic the estimate. 5 Clinicians may also have trouble with prognostic uncertainty. Some react with an unwillingness to talk to the patient about the future at all (but commonly express this unwillingness in terms such as "we have to wait and see" or "no one can tell").…”