Public Release: 

Rate of physician referrals nearly doubled

Increase in referrals could lead to increase in health care costs

Harvard Medical School

BOSTON, MA -- 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.

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This research was funded by the Department of Health Care Policy at Harvard Medical School.

Zirui Song was supported by a Pre-doctoral M.D./Ph.D. National Research Service Award from the National Institute on Aging and a Pre-doctoral Fellowship in Aging and Health Economics from the National Bureau of Economic Research.

--Jake Miller CITATION

Archives of Internal Medicine, Jan. 23, 2012

"Trends in Physician Referrals in the US, 1999-2009" by Barnett et al

Harvard Medical School <http://hms.harvard.edu> has more than 7,500 full-time faculty working in 11 academic departments located at the School's Boston campus or in one of 47 hospital-based clinical departments at 17 Harvard-affiliated teaching hospitals and research institutes. Those affiliates include Beth Israel Deaconess Medical Center, Brigham and Women¹s Hospital, Cambridge Health Alliance, Children¹s Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Hebrew SeniorLife, Joslin Diabetes Center, Judge Baker Children¹s Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.

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