Dropping the Baton: Specialty Referrals in the United States

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.

Studies have found that 25 to 50 percent of referring physicians did not know whether their patients had actually seen the specialist to which they were referred (Bourguet, Gilchrist, and McCord 

Poor referral tracking leads to inappropriate re-referrals, inefficient care, worse patient satisfaction, and malpractice lawsuits (Gandhi et al. 2006).

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Approximately one-quarter of U.S. patients reported that the results and records from one provider did not reach another provider in time for their appointment (Blendon et al. 2003Schoen et al. 2009).

The information, if sent, is frequently sent late. In one study, 25 percent of letters from specialists were not timely enough to “affect decisions” (McPhee et al. 1984). Gandhi and colleagues noted that at an academic institution with a shared electronic medical record, specialists failed to provide letters within seven days of a referral in 36 percent of cases (Gandhi et al. 2000). They also noted that 50 percent of referring physicians were dissatisfied with the timeliness of specialists’ feedback (Gandhi et al. 2000).

In addition to timeliness, there is the issue of adequacy of communication. Specialists believed that the inadequate content of referral letters commonly caused problems in the referral process (Gandhi et al. 2000); the specialists were not always sure why a patient was referred (McPhee et al. 1984); the specialists and the referring physicians disagreed on the reason for referral in 14 percent of cases involving inpatients (Lee, Pappius, and Goldman 1983); and 70 percent of the specialists rated the background information they usually received as fair or poor (Tanielian et al. 2000). Inadequate communication from specialists also is an issue. In one study, more than half the referring physicians needed more feedback information than was provided by the specialist (Williams et al. 2005), and in another, the referring physician was dissatisfied with the feedback in 17 percent of cases (Byrd and Moskowitz 1987).

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Things had gotten so bad at the Bronx veterans hospital that doctors were, in effect, begging their patients to show up as scheduled.

Three years ago, the James J. Peters VA Medical Center began a “Don’t Be A No-Show” campaign, reminding veterans of the importance of keeping appointments. Read more…..

Communication Breakdown in the Outpatient Referral Process

Several studies show that letters from general practitioners often lack critical information, explicit statements of the reason for consultations, sociopsychological factors, or plans for follow-up. Communication issues are important for physician satisfaction and for quality of care. Physicians making referrals have switched hospitals and specialists because of poor communication. Specialists were also dissatisfied with the timeliness of information they received, and 68% reported that they did not receive information before the referral visit.

Also, PCPs reported a 19% repeat referral rate due to problems not completely addressed at the first visit, some of which may be related to inadequate initial communication. Thus, both cost savings and better quality of care could result from improved referral note content and timeliness.

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19.7M “Clinically Inappropriate” Physician Referrals Occur Each Year

Nearly 20 million times a year in the U.S., patients are sent to a doctor who is not the right match for their specific condition. This is one of many key stats in the new physician referrals survey conducted by Kyruus,that highlights the massive issues in the doctor-patient referral system.

75 percent of specialists have received at least one “clinically inappropriate” referral in the past year.

26.2% of referrals are potentially inappropriate: 18.4% of referrals to specialists in the last year were
considered “somewhat appropriate” while 7.8% are considered “inappropriate”.

65% of of clinically inappropriate referrals were either sent to the wrong specialist or subspecialist (48%) or did not require a referral at all (17%).

What causes inappropriate referrals? 87 percent of physicians believe that referral misdirection happens when there is a lack of reliable information about the specialists.

Of the patients who are referred incorrectly, 63 percent are re-referred to more clinically suitable physicians, incurring an estimated $1.9 billion in lost wages and unnecessary co-pays annually.