Physician Referral Patterns Ripe for Scrutiny

Cheryl Clark, for HealthLeaders Media , January 26, 2012

"So why do we do this? It's because that's how the specialist gets paid. If the primary care provider calls a cardiologist and says, 'I have Mrs. A, and she's on drug one, two, and three and still short of breath, what would you suggest?' then the specialist does not get paid."

Katz says that one thing he and other health policy officials are trying to do in public systems is "replace visits as the goal with improving the patient's care as the goal. And sometimes that will mean a visit. But sometimes it would mean calling up the specialist and point to an image or an electronic medical record."

Landon says that from published research so far, he can't estimate how many specialty referrals are unnecessary. "It's not a simple answer," he acknowledges. "But that's something we're very interested in learning about in the future."

It appears that learning opportunities are definitely on the horizon.

As practice and referral patterns change with bundled payments, increased hospital employment of physicians, the growth of accountable care organizations and, of course, more transparency with quality data on Physician Compare beginning next year, I can't wait to see what the referral landscape looks like in a few more years.

As Katz says in his editorial, the solution does require financing reform. "If instead, payments for groups of patients are bundled, then generalists and specialists can organize their services in the most cost-effective way."


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2 comments on "Physician Referral Patterns Ripe for Scrutiny"

Carri D (1/30/2012 at 10:45 AM)
The CMS changes that occurred in 2011 were radical and strongly enforced. I worked in an university oncology setting that bordered other states. Patients would frequently transfer to our facility for more complex treatments..If referrals for home health PT/OT were needed, our doctors orders were no longer accepted. Regulations stated all orders must be written by a MD from patients state. I understand the logic, but explain that to a patient who depends on you for quality care and a doctor who has been writing these orders for decades. The paperwork took away from the quality of care the patients deserved. Shameful Don't get me started on the HUGE cuts in "units" ie medications for terminally ill patients. Beyond shameful. After three days of battling with an insurance company over pain meds. Being told the patient would have to wait 2 wks for a refill. Oxycontin tabs went from 30 for 30 day cycle to 12! In despair I asked if this is when we start taking people out back and shooting them to end their pain and suffering. My patient got her medications. I lost my job.

Gus Geraci, MD (1/27/2012 at 4:54 PM)
The answer is: All of the above! Sometimes it is a waste of money and sometimes it is critically necessary to provide better care. The problem is there is no simple analysis of the why, because it is an interplay of the patient's needs, the patients' demands, the physician's skill and comfort, busy-ness, and reimbursement and other factors. Adjusting reimbursement for outcomes and quality will help.




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