BACKGROUND. Primary care physicians (PCPs) exhibit widely varying referral
rates, resulting in dramatic differences in the exposure of their patients
to specialists. The relationships between this physician behavior and costs
and patient outcomes are unknown.
OBJECTIVES. To examine the relationships between PCP referral rates and cos
ts, risk of avoidable hospitalization, health status, and satisfaction.
DESIGN. Cross-sectional analyses of claims and patient survey data.
SETTING AND SUBJECTS. Independent practice association (IPA)-style managed
care organization in the Rochester, NY, metropolitan area. The 1995 claims
data included 457 PCPs in the IFA and 217,606 adult patients assigned to th
eir panels. Approximately 50 consecutive patients of each of a random sampl
e of 100 PCPs completed a patient survey in 1997-1998.
MEASURES. From the claims data, total expenditures per panel member, the ri
sk of avoidable hospitalization, and physician referral rate were measured.
Measures derived from the survey included SF-12 scores, satisfaction, and
physician referral rate.
RESULTS. The relationship between physician referral rate and per-panel-mem
ber costs was not statistically significant after case-mix adjustment of th
e referral rate. There was no relationship between the case-mix-adjusted re
ferral rate and risk of avoidable hospitalization. In the survey data, ther
e was no adjusted relationship between the physicians' referral rate and th
eir patients' self-rated physical or mental health. There was a modest dire
ct relationship between patient satisfaction and survey-derived referral ra
te.
CONCLUSIONS. Despite stable, wide variations in PCP referral rates, there a
re few discernible relationships between this physician behavior and costs
and patient outcomes. Efforts to constrain PCP referrals to specialists may
be misguided.