Process changes, but skill still top factor in referrals

A study looks at the decision-making process primary care physicians use when selecting a specialist.

By Damon Adams — Posted July 19, 2004

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Before managed care, family physician Jim King, MD, used a smaller number of specialists for patients. He would call the specialist, make sure the doctor was available, then send over his patient.

The process isn't as simple these days.

"The first question has changed from what problem do they have to what insurance do they have," said Dr. King, who practices in Selmer, Tenn., and is a board member of the American Academy of Family Physicians.

After checking on a patient's insurance coverage, Dr. King looks at the specialist's medical skill. Then he considers the working relationship he has with the specialist.

Dr. King's process for choosing a specialist is similar to those of other primary care physicians, according to a new study in the May/June Annals of Family Medicine. The national study examined what factors primary care physicians consider when selecting specialists for their patients. Approximately 4.5% of all patient visits in the United States lead to referrals, and doctors get up to 45% of new patients by referral, the study said.

In the study, a specialist's medical skill was viewed as the most important factor by 88% of doctors -- the highest amount of any factor in selecting a specialist. The next highest factor was previous experience with a specialist, cited by 59% of the 623 primary care physicians in the study. Appointment timeliness was listed third in importance.

About half of respondents placed great value on quality of communication with a specialist, likelihood of good patient-physician rapport, returning the patient to the referring doctor and insurance coverage.

Least important when picking a specialist were medical school and institution of fellowship training, patient referrals from the specialist, office location and hospital affiliation.

"If I was a specialist I would look at this very carefully because it would tell me what I would need to be doing" to get referrals, said Neil R. Powe, MD, MPH, professor of medicine, epidemiology and health policy and management at the Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore.

Race and gender differences

Researchers found some differences based on race and gender. For example, white physicians were more likely than black physicians to place more importance on previous experience with the specialist and on board certification. Female doctors were more likely to rate insurance coverage of greater importance in referral decisions.

"Men were more concerned about returning patients [to them]. Women seemed more concerned about patient coverage," Dr. Powe said.

New Orleans internist Kathleen W. Wilson, MD, agrees with other doctors who said that over time managed care plans have loosened their restrictions, making it easier to send patients to specialists. But she is among those primary care physicians who want to make sure patients have insurance coverage before sending them to specialists.

Dr. Wilson also likes specialists who keep her posted about her patients' progress.

Some things won't lead to a referral from Dr. Wilson. She will pick another specialist if the wait at one specialist is too long. If she gets feedback that a specialist was disrespectful or mistreated a patient, Dr. Wilson won't use that specialist again.

"I prefer a specialist or surgeon who gets a good result [for patients] every time. That's the No. 1 important thing for me," she said.

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Talent rules

Skill is the key consideration of primary care physicians when choosing a specialist for referral. Least important is where a specialist went for medical school and fellowship training. Physicians who say factor is "very important":

Medical skill 88%
Previous experience with specialist 59%
Appointment timeliness 55%
Quality of communication 53%
Likelihood of good patient-physician rapport 51%
Specialist returns patient to primary physician 51%
Insurance coverage 50%

Source: "Referral of Patients to Specialists: Factors Affecting Choice of Specialist by Primary Care Physicians," Annals of Family Medicine, May/June. Note: Percentages are rounded.

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Referral rates

Primary care doctors tend to be do-it-yourselfers, with the majority of referring physicians sending less than 10% of patients to specialists in any given week.

who refer
Less than 5% 22.5%
5%-10% 43.4%
11%-15% 19.9%
16%-20% 10.2%
More than 20% 4.0%
Total 100%

Source: "Referral of Patients to Specialists: Factors Affecting Choice of Specialist by Primary Care Physicians," Annals of Family Medicine, May/June

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External links

"Referral of Patients to Specialists: Factors Affecting Choice of Specialist by Primary Care Physicians," Annals of Family Medicine, May/June (link)

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