Ambulatory physician referrals nearly doubled in past 10 years

The probability that an ambulatory visit resulted in a referral to another physician almost doubled from 1999 to 2009, while the absolute number of visits resulting in a physician referral increased 159% during the decade, according to a study.

During the same time, referral rates for Medicare patients more than doubled (from 4.2% to 9.7%; P=0.003). Combined with the increase in the number of visits annually, the total number of Medicare visits resulting in a referral increased more than 350%, the study found.

Researchers analyzed a sample of 845,243 visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for the study, the results of which appeared in the Jan. 23 Archives of Internal Medicine.

From 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral increased from 4.8% to 9.3% (94%; P<0.001). The 159% increase in absolute visits that resulted in a physician referral represents a numeric increase from 41 million visits to 105 million.

In office-based physician practices, physician referral rates increased 97% from 1999 to 2009 (from 4.4% to 8.6%; P=0.004). Outpatient department-based practices associated with hospitals had an 84% increase from 9.0% to 16.6% (P<0.001) despite a baseline referral rate more than twice as high as office-based physicians.

For primary care physicians, changes in referral rates varied according to the principal symptom:

• cardiovascular (from 8.5% to 14.9%; P=0.001),
• dermatologic (from 10.1% to 15.4%; P=0.03),
• ear/nose/throat (from 4.5% to 8.5%; P<0.001),
• gastrointestinal (from 12.3% to 17.7%; P=0.007), and
• orthopedic (from 12.4% to 16.5%; P=0.003).

Other kinds of visits, such as general/viral, gynecologic/breast, and ocular, had statistically nonsignificant changes.

Specialist physicians also significantly increased their referrals for three of the same symptom categories:

• ear/nose/throat (from 3.8% to 7.4%; P=0.01),
• gastrointestinal (from 3.8% to 10.6%; P<0.001), and
• orthopedic (from 4.6% to 8.8%; P<0.001).

Specialists also increased referrals for gynecologic/breast (from 3.7% to 5.8%; P=0.04) and psychiatric (from 1.9% to 3.5%; P=0.005) issues.

One possible reason for the increase in referrals is that care is becoming increasingly complex, the authors wrote. The need to fit more clinical demands into the same length of an appointment may also play a role, the authors wrote. Finally, there are more specialists to refer to.

An editorialist commented that primary care physicians and specialists are beginning to communicate about the needs of their patients through electronic health records and even phone calls, which could focus the need for consultation and therefore eliminate many visits.

“For this new vision of patient referral to be fully realized, we will need financing reform,” the editorial stated. “As long as visits are reimbursed but electronic communication and cognitive time are not, referral visits will only grow. If, instead, payments for groups of patients are bundled, then generalists and specialists can organize their services in the most cost-effective way.”