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Self-referral to Specialists

By February 17, 2014Commentary

There are a many sources of tension in the health care system.  One is between the goal of having highly coordinated care for a patient, typically directed by a primary care physician, and the desire to have patients be more informed, more involved in their health care decisions and acting autonomously in that regard.  Self-referral to specialists by patients is an interesting example of this dilemma.  On the one hand, a patient may have researched his or her health issue and evaluated the providers who typically care for that health problem and decided that a particular physician is the right person to see; and on the other hand, that behavior makes it harder to coordinate care and limit inappropriate utilization and spending.  An article in the American Journal of Managed Care explores self-referral trends.    (AJMC Article)   The researchers used ten years (2000-2009) of survey data from the National Ambulatory Medical Care Survey of physicians and compared self-referral rates over time and within the Medicare and privately insured population.

Overall, outpatient visits and referrals to specialists have increased in the time period of the study.  For the ten most common specialties self-referral rates between Medicare beneficiaries and commercial health plan members were relatively similar, except for ophthalmology and psychiatry, where the privately-insured had higher rates of self-referral.  For both groups, the absolute number of self-referred visits was relatively flat over the study time period, but since overall referrals to specialists grew, self-referrals declined as a proportion of all referrals.  The rates, however, at 20% for Medicare beneficiaries and 25% for commercial members, are significant enough to warrant further attention in regard to their potential to hinder care coordination.  Self-referral rates vary significantly by specialty as well, which may indicate the need to focus on issues in the specialties with high self-referrals.

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