When I spoke with him this week, the pitch of Katz' voice conveyed his astonishment, or at least his umbrage. "The thing I was most struck by is this," he told me. "Here's this major increase in the number of specialty referrals. But there's no consensus on guidelines on who should go to a specialist. Like any intervention, we should know, okay, what are the indications for sending someone to see, say, a pulmonologist?
"It turns out we don't have any indications. I thought that was really surprising because we spend a huge amount of American dollars on specialty care," says Katz, former public health director for the County of San Francisco and an architect of Healthy San Francisco.
That's unlike most procedures or drugs, or imaging studies, where there are guidelines, he says.
He points out that the U.S. has two specialists for every primary care physician, where in Western Europe, the ratio is reversed.
Then Katz says something bound to be controversial: he believes that "most" primary care physicians' referrals to specialists in the U.S. "are unnecessary."
He says, the fact specialists so outnumber primary care practitioners in this country "is one of the often given reasons—and certainly I believe it—why we have so much higher costs but poorer outcomes than most of Western Europe," he says.