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.”