Introduction

This concept contains information about referral rates from primary care physicians to specialists, including how this is defined and the methods used to implement this from administrative data. The concept also contains links to specific MCHP research that provides more detailed information on referral rates.

Information for this concept comes directly from the deliverable Physician Integrated Network: A Second Look by Katz et al. (2014).

Defining Referrals and Referral Rates

Referrals from primary care physicians (family physicians (FP) to specialists are a routine part of primary care. The decision to refer a patient is based on a number of factors and has a number of consequences for the patient and the healthcare system. While analysis of administrative data does not allow evaluation of the appropriateness of any one specific referral, practice-based analysis does suggest a pattern of clinical behavior. Previous research has demonstrated significant differences in referrals that are extremely unlikely to be a reflection of individual patient need based on differences in disease pattern (Liddy et al., 2014). For example, fee-for-service physicians have been shown to have lower referral rates than physicians funded through other mechanisms. Previous research has suggested that patients tend to be referred for specialist care more often by physicians who do not have an ongoing therapeutic relationship with the patient.

We calculated the rate of referrals three ways:


1. rate of referral by the patient's own assigned family physician,
   
2. rate of referral by any family physician working at the same clinic, and
   
3. total referrals - includes any family physician seen regardless of where they work.

The following exclusions were made:


• referrals made to pathology, radiology, anesthesia and other primary care physicians (FPs) - (mdbloc = 07, 08, 10 and 11),
  
• all obstetrical referrals due to a normal pregnancy (ICD-9-CM codes V22-V28), and
  
• referrals from the same physician to the same specialist within 6 months of the first referral.

When looking at the referral rates from physicians at the same clinic we were unable to have shadow practices; therefore, we only looked at changes over time (pre and post implementation).

Referral rates are expressed as a per-person rate and theoretically could be greater than 1.0 because one person can get more than one referral. All the rates are based on ambulatory visits found in the Medical Services (Physician Claims) data.

Referral Rates in MCHP Research

There is no "correct" rate of referral inferred in our research, but we are able to provide comparisons.


• In Katz et al. (2014), they compare referral rates for before and after implementation of Physician Integrated Network (PIN) clinics, between PIN clinic patients and their matched shadow practices. See the section titled Referral Rates for more information.