Context: In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines.

Methods: This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care.

Findings: PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management).

Conclusions: There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.

/pdf/dropping-the-baton-specialty-referrals-in-the-united-states-l8weodr3ly.pdf

Dropping the baton: specialty referrals in the United States.

Purpose. To examine the effects of patient, physician, and health care system characteristics on primary care physicians’ (PCPs’) specialty referral decision making. Methods. Physicians (n = 142) a...

/pdf/primary-care-physician-specialty-referral-decision-making-2zntxv8s6f.pdf

Primary care physician specialty referral decision making: patient, physician, and health care system determinants.

PURPOSE The impact of comorbidity on use of primary care and specialty services is poorly understood. The purpose of this study was to determine the relationship between morbidity burden, comorbid conditions, and use of primary care and specialist services

METHODS The study population was a 5% random sample of Medicare beneficiaries, taken from 1999 Medicare files. We analyzed the number of ambulatory face-to-face patient visits to primary care physicians and specialists for each diagnosis, with each one first considered as the “main” one and then as a comorbid diagnosis to another. Each patient was categorized by extent of total morbidity burden using the Johns Hopkins Adjusted Clinical Group case-mix system.

RESULTS Higher morbidity burden was associated with more visits to specialists, but not to primary care physicians. Patients with most diagnoses had more visits, both to primary care and specialist physicians for comorbid diagnoses than for the main diagnosis itself. Although patients, especially those with high morbidity burdens, generally made more visits to specialists than to primary care physicians, this finding was not always the case. For patients with 66 diagnoses, primary care visits for those diagnoses exceeded specialist visits in all morbidity burden groups; for patients with 87 diagnoses, specialty visits exceeded primary care visits in all morbidity burden groups.

CONCLUSION In the elderly, a high morbidity burden leads to higher use of specialist physicians, but not primary care physicians, even for patients with common diagnoses not generally considered to require specialist care. This finding calls for a better understanding of the relative roles of generalists and specialists in the US health services system.

https://www.annfammed.org/content/annalsfm/3/3/215.full.pdf

Comorbidity and the use of primary care and specialist care in the elderly.

The use of primary care physicians as gatekeepers to specialists and other medical resources—considered to be a managed care innovation in the United States—has proliferated during the past few decades. Its introduction has been accompanied by a government sponsored programme of research into referrals from primary care (box 1). Findings from these studies may offer insights into how the UK's NHS could shape the gatekeeping function of general practitioners. This article discusses the concept of gatekeeping, contrasts the processes of referral to specialists in the United States and the United Kingdom, examines the mechanisms by which gatekeeping influences resource allocation, and discusses the effects of linking gatekeeping with financial incentives and utilisation review.

#### Summary points

Gatekeeping systems have emerged in countries with scarce medical resources

Gatekeepers ensure equity by judiciously matching healthcare services, including specialty referrals, to healthcare needs

Gatekeeping alters patients' behaviour, increasing levels of first contact care with primary care physicians, thereby reducing patients' self referrals

Patients in US health plans with gatekeeping arrangements are twice as likely to be referred to specialist care as their UK counterparts

There is little evidence that gatekeeping has had much effect on patients' referral rates in the United States, a healthcare environment rich in specialists

Within modern societies, gatekeepers are positioned between organisations and individuals who wish to use resources within those organisations. Gatekeepers use discretion when determining who will be granted access to these resources. Physician gatekeepers collaborate with patients to identify their healthcare needs and choose services that effectively meet those needs. Public acceptance of gatekeeping is strengthened when there are too few resources to satisfy everyone's demands. In the United Kingdom, where long queues to see specialists are common because specialists are in short supply, the general practitioner gatekeeper has enjoyed widespread support. In the United States, the public perceives …

https://www.bmj.com/content/bmj/326/7391/692.1.full.pdf

Primary care in the United States: primary care gatekeeping and referrals: effective filter or failed experiment?

● Many medical presentations contain significant psychological comorbidity. Strosahl and Robinson point out in Chap. 8 that presentations that are for specific psychological or substance abuse issues are infrequent. More often, psychological issues are found to be part of acute medical issues, such as sleeping problems, headache or gastrointestinal problems, as well as complex chronic medical conditions such as diabetes, cardiac conditions or pain.

https://www.springer.com/cda/content/document/cda_downloaddocument/9780387768939-c2.pdf?SGWID=0-0-45-520933-p173784519

Primary care is the de facto mental health system.

OBJECTIVE To examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer. STUDY DESIGN Prospective cohort study. POPULATION All visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states. OUTCOMES MEASURED Rates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists. RESULTS Approximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician-gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist. CONCLUSIONS Referrals are commonly made during encounters other than office visits, such as telephone conversations or staff-patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

von Schrader S

Papers

Family physicians' referral decisions: results from the ASPN referral study.