Patient desire and reasons for specialist referral in a gatekeeper-model managed care plan

Objective: To describe patient desire and reasons for specialist referrals in a gatekeeper-model managed care plan. Study Design: Cross-sectional prospective study. Patients and Methods: We developed a patient questionnaire to gather demogr aphic data and to gauge patients' desire for specialist referral and their reasons for seeking such referral. The survey was administered at 2 sites-a n ambulatory care facility of a university hospital and an internal medicin e clinic in a suburban ambulatory care site. Patients asked to complete the questionnaire at the university hospital site were enrolled in a gatekeepe r-model managed care plan (called CU Cold); those seen at the internal medi cine clinic were enrolled in a group-model health maintenance organization. Patients were asked to complete the 1-page questionnaire in the waiting ro om before being seen by their primary care physician. Results: Among the 860 CU Gold patients who met the inclusion criteria duri ng the 3-month study period (September to December 1997), 112 (13%) reporte d a definite desire to see a specialist and 274 (32%) indicated a possible desire to see a specialist at the time of their primary care visit. Compare d with the CU Cold patients, significantly fewer patients in the health mai ntenance organization indicated a definite desire to see a specialist (3% v ersus 13%), but a similar percentage expressed a possible desire to see a s pecialist (30% versus 32%). The difference in definite desire for referral between the 2 groups could not be explained by patient or primary care phys ician characteristics. The principal health concerns for which patients sou ght referral were musculoskeletal, genitourinary or gynecologic, or dermato logic problems. Need for reassurance (cited by 67% of patients), seeing a s pecialist before (56%), and believing the primary care physician lacked exp ertise (49%) were the primary reasons patients sought referral. Seventy-fou r percent of patients referred by their primary care provider and 54% of th ose not referred agreed it was a good idea to see their primary care physic ian first before seeing a specialist. Conclusions: Patients have a significant desire for specialist referral, dr iven by their need for reassurance, previous specialist referral, and belie f that their primary care physician does not have the requisite expertise. Patients' expectations for referral varied significantly, depending on the healthcare system (academic primary care clinic or health maintenance organ ization) in which they were enrolled.