Rate of physician referrals nearly doubled

Physician referral rates in the United States doubled between 1999 and 2009, a new study finds, an increase that likely contributes to the rising costs of health care.

The increase in referral rates coincides with an increase in chronic conditions such as Type 2 diabetes. The results are staggering: over the same time period, the estimated absolute number of visits resulting in a referral increased 159 per cent, from 40.6 million to 105 million.

"If you add that up, it's real money," said Bruce Landon, senior author of the paper and professor of health care policy at Harvard Medical School.

The researchers found a 92 percent increase in referral rates (from 4.83 to 9.29 percent) over the last decade, analyzing a nationally representative sample of 845,243 ambulatory patient visits from the National Ambulatory Medical Care Surveys, 1993-2009.

"Understanding trends in physician referrals is critical both for improving patient care and for managing costs," said Michael Barnett, lead author on the study and a first-year resident in internal medicine and primary care at Brigham and Women's Hospital.

The results will be published January 23 in the Archives of Internal Medicine. For many years, the rate of referrals stayed flat, until about ten years ago, when they began a steady climb. This paper is the first research to analyze referral data since the trend began. The marked increase in referral rates is likely due to increased specialization in medical care, and increasing responsibilities for primary care physicians during a typical visit. "Sometimes physicians may find it easier to refer a patient to another doctor than to find the necessary time to spend with him or her," said coauthor Zirui Song, an HMS student and PhD student in health policy.

The researchers noted that referrals to specialists are often gateways to a cascade of potentially costly services which may or may not be needed: The cost associated with a referral isn't just the cost of a single visit, it's the potential for an ongoing series of visits, diagnostic tests, procedures and hospitalizations that might result.

In some cases, a more conservative approach can have better results and lower costs. For example, instead of referring a patient with ankle pain for an MRI and a visit to an orthopedist, a primary care physician might first recommend rest and physical therapy.

"This study is step one, an attempt to start to get our heads around the question by describing the basic epidemiology of physician referrals," said Landon. In order to manage the rising costs of health care and guarantee the best outcomes for patients, he added, researchers need to understand the interactions between networks of referring physicians and the appropriateness of referrals.