The specialist referral: Do primary care providers have all the information they need?

November 17th, 2017 / By Steve Delaronde

The role of the primary care provider is to serve as a generalist in managing their patients’ health. Specialists are available to provide expert opinion or specific procedures beyond the scope of the primary care provider. Ideally, most patient complaints would be handled by their primary care provider, whether an internist, general practitioner, pediatrician, nurse practitioner or physician assistant. The trend for PCPs to refer more of their patients to specialists, as well as the tendency for patients to bypass a PCP entirely and self-refer to a specialist, has implications for managing quality, cost, and overall outcomes within a patient population.

Specialist referrals have been gradually increasing.  Nearly 1 in 10 visits to a PCP resulted in a specialist referral in 2009, compared to 1 in 20 just 10 years earlier.  Patient complaints that lead to the most referrals are related to vision (21 percent), gynecological (18 percent), gastrointestinal (18 percent), orthopedic (16 percent), dermatological (15 percent), and cardiovascular (15 percent). Over the entire year, about 1 in 3 patients under 65 years old that visit a PCP in the United States is referred to a specialist, which is more than twice as many that get referred to a specialist in the United Kingdom.

When making a referral, the PCP often has very little information on specialist cost or quality, as well as specialist suitability to the patient’s specific needs and geographic location. PCPs also vary in their referral rates with some PCPs making more than 5 times as many referrals as others. There are many reasons for this variation in referral practice related to both the patient, PCP and pool of specialists. Because most PCPs rely on their clinical judgement rather than guidelines when making referrals, and specialist access is not the same for all patient groups, wide variation is inevitable.

The variability in referral patterns can lead to under-referral as well as over-referral. Under-referral can lead to patients not getting the expert opinion and care that they may need to treat their condition, while over-referral can lead to higher risk and unnecessary cost. It is acknowledged among most specialty groups that up to one-third of procedures are medically unnecessary and expose the patient to unnecessary risks. Physicians may also use a specialist to mitigate their own liability that could occur with a missed diagnosis or allegation that they are not doing everything possible to treat the patient. This trend towards specialist referrals is likely to continue as medicine becomes more complex.

The patient’s visit to a specialist is often outside the direct control of the PCP. Most health plans do not require patients to get a referral from their PCP to obtain specialist care.  This makes it even more imperative for a strong physician-patient relationship in which the PCP can guide patients towards the best treatment and specialty care, when needed. Patients who do not regularly visit their PCP may be more likely to self-refer to specialists than patients with a chronic condition that regularly visit the PCP.

Since specialty care will continue to dominate the U.S. healthcare market, it is imperative for PCPs to have information that will help them make decisions that are in the best clinical and financial interest of their patients. This includes referrals for routine procedures such as colonoscopies, one of the most common reasons for a medical referral. This type of procedure may have low variability in quality, but high variability in cost

Referrals for the care of chronic conditions, such as diabetes, heart disease, and cancer are even more significant, since the costs are higher, as well as the variability in both cost and quality. Specialist cost and quality indicators can be gathered from the electronic health record, as well as administrative claims data. Risk-adjusted preventable events, such as hospital readmissions and emergency room visits, as well as post-discharge follow-up and medication adherence rates can all be calculated using medical claims data.

As the trend towards high deductible health plans accelerates, patients are increasingly accountable for the cost of their healthcare treatment. As the trend towards value-based care continues, PCPs are increasingly accountable for the total cost and quality of care delivered to their patients. Both trends mean that a more standardized and transparent method for PCPs and patients to make the best choices possible for specialty care will be mutually beneficial.

Steve Delaronde is director of analytics for populations and payment solutions at 3M Health Information Systems.