A referral to a specialist turns patients into currency

Most insurance plans require primary care doctors to refer patients to specialists, like surgeons, cardiologists, and dermatologists.

Without a primary care source of patients, specialists will be without patients, and like any business, their practice will suffer as a result.

In a recent essay, cardiologist Sandeep Jauhar talks about this system. He writes of an ironic paradox where primary care doctors yield a rare display of power: “Specialists are better paid than primary care physicians, but they are also less autonomous because, unlike primary care physicians, they depend on other doctors for referrals. There is pressure on specialists to keep referral sources happy.”

The United States provides more specialist-based care than any other country in the world. For instance, specialist referrals are at least twice as high in the United States when compared to the UK. Especially in our system where quantity is valued, there is more incentive than ever to consult a specialist for routine problems.

Indeed, an oft-unspoken dynamic is at work, one where Dr. Jauhar observes that “there is plenty of evidence that wasteful expert consultation is adding to health costs and creating redundant care. But as a full-fledged doctor, I appreciate the business. It is hard not to view a referral as an overture from another physician, and it is equally hard not to return the favor.”

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  • http://rk.md Rishi

    This is an ironic state of affairs; however, I find it difficult to imagine the alternative – patients directly visiting specialists. How would some patients even know what kind of specialist to visit without a referral?

  • K

    “How would some patients even know what kind of specialist to visit without a referral?”

    My insurance doesn’t require a referral to a specialist and I do just fine. When it is clear I need a specialist, I find a visit to my PCP delays diagnosis and treatment and also makes the episode more expensive. During a especially difficult health care issue, I received referrals from the specialists to other specialists. My PCP was unable to keep up and I am grateful that I was taken care of promptly instead of having to wait months for an opening in my PCP’s schedule.

  • http://twitter.com/chukwumaonyeije CIO

    Another significant issue is that patients are being increasingly referred by PCPs for issues which do not seem to require specialty care. Subspecialty input in such cases is often superfluous or unnecessary and it is definitely more expensive to the patient and /or insurer. In the past, PCPs would have handled such cases by themselves however, (for a variety of reasons) they now refer such cases to a specialist.

    The result is patient frustration, more expense (and I fear) less value. Specialists fees notwithstanding… Everyone loses.

    Reference: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

  • k

    @Rishi -
    Many insurance plans no longer require PCPs to act as gatekeepers. That was one of the driving forces away from the late 80s-early 90s highly restrictive HMOs toward PPOs.

    Yes, some are sufficiently unaware of their medical conditions and therefore unable to choose the correct specialist. Others can’t choose specialists for financial reasons (e.g. Medicaid, uninsured).

    If you’ve had a recurring issue or a particular condition for any length of time, it’s pretty easy to figure out what kind of “part doctor” you need to see without going through a PCP first. .

  • http://brucesmallsurveys.typepad.com/ Bruce Small

    Knowing what kind of specialist is usually the easy part. The advantage of going through my PCP is that he knows the really good ones, and which ones to avoid.

  • AnnR

    My PCP knows all the easy tricks. There is no virtue in a fancy solution when a simple one will do.
    My situation is made easier because my PCP has same-day scheduling.

  • ray

    For the really savvy patients it may be helpful to self refer but only a minority will benefit in this way and honestly which specialist will say – you really don’t need any further testing when patients are the money makers for them. Most insur still need PCP referrals. My uncle once self referred himself to cardiologist for what he thought was chest pain, got the whole nine yard work including angio ( My uncle was jogging 2 miles per day at that time) which was 100% clean. After a month of onging pain went to his PCP and it turned out he had a gall bladder infection which needed extensive complicated surgery since he waited too long. My Uncle said, ” The cardiologist looked me through a hole and didn’t see me as a whole.” If we give enough incentives and reward doctors to spend time with patients instead of chasing one test after another, we will all be at a better place. What incentive will a primary care doc have to spend an half hour with patient and make follow up phone calls? He will be penalised for his effort and labeled inefficent by the system.

  • lottus

    “Knowing what kind of specialist is usually the easy part. The advantage of going through my PCP is that he knows the really good ones, and which ones to avoid.”

    maybe yr pcp receives financial kickbacks from specialists for each referral he makes?

    Probably does. Wake up and smell the coffee/

  • A specialist

    I actually prefer that patients come to me without a primary care referral. Many referrals now are simply to cover the primary care’s a$$ and are a waste of my time and the patients time. As k mentions above, requiring initial evaluations by primary care often delays care and referrals are directed often for monetary reasons (you rub my back and I will rub yours) rather than for the benefit of the patient.

  • family physician

    Hey lotus: you smell the coffee. Nobody is getting kickbacks.

    Hey specialist: what type of specialist are you?

  • http://brucesmallsurveys.typepad.com/ Bruce Small

    “maybe yr pcp receives financial kickbacks from specialists for each referral he makes? Probably does. Wake up and smell the cof”

    You made the illogical jump from maybe to probably in consecutive sentences, but without a shred of evidence and without knowing anyone involved. Arrogant is the word, apparently mixed with anger and envy. Bad combination.

  • Frank Drackman

    Umm pickin a specialist isn’t THAT hard…and even if you are a mouth breather, the yellow pages makes it pretty easy, even putting “DIABETES” in parentheses next to “Endocrinologists”, and for the illiterate, theres a nice drawing of a “Heart” for “cardiology”…

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