Pediatric referrals on the (surprise!) upswing


Despite widespread concern about the limitations managed care organizations place on referrals, pediatricians are sending patients to subspecialists more often now than in the past, our latest survey shows.

Pediatric referrals on the (surprise!) upswing

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Choose article section... Which conditions are referred? Where the referrals go


Despite widespread concern about the limitations managed care organizations place on referrals, pediatricians are sending patients to subspecialists more often now than in the past, our latest survey shows.

The restrictions managed care organizations (MCOs) place on primary care doctors who wish to refer patients to specialists have caused physicians and patients to worry that they may not always have access to specialty help when they need it. Yet a nationwide study Contemporary Pediatrics recently conducted on referral practices shows that pediatricians are referring patients more frequently now than they did a decade ago. In 1999, pediatricians referred an average of 18 patients to subspecialists each month compared with an average of 12 patients a month in 1988, even though in the number of patients pediatricians saw each month decreased during this period.1,2 The increase in pediatric referrals mirrors the rise in referral rates for all primary care physicians. From 1989 to 1994, generalists (family practitioners, pediatricians, and internists) in HMOs increased referrals for specialty care by 58% and those in indemnity plans, by 27%.3

Which conditions are referred?

The questionnaire we sent to 2,000 pediatricians, nearly 30% of whom responded, was similar to one we used in a 1988 survey, except that the earlier survey did not ask about managed care. We queried the pediatrician about how often he or she referred a patient with any of 54 diagnoses to a subspecialist: never (0% of the time), rarely (1%­10% of the time), occasionally (11%­25%), sometimes (26%­50%), usually (51%—75%) or almost always (76%­100%). The conditions pediatricians refer most frequently are suspected leukemia in a 3-year-old, suicide gesture, hemophilia, and cystic fibrosis. Table 1 lists the conditions referred more than half the time. Least likely to be referred are acute sinusitis, first urinary tract infection, an uncomplicated febrile seizure, iron deficiency anemia, or an asthma attack (Table 2). Most pediatricians (70%) said they refer the same number of patients as they did three years ago, while 18% thought their referrals had increased. The remaining 12% believe they make fewer referrals than they did three years ago.




Doctors who have been in practice 11 to 20 years or more are more likely to refer certain conditions than doctors who have been in practice one to five years, and vice versa (Table 3). Even though male pediatricians make more referrals than female pediatricians (19 patients a month compared with 16), the list of conditions women are more likely to refer than men is far longer than the other way around (Table 4). Men and women were equally represented in the survey. Some conditions are less likely to be referred in rural areas than in urban areas (Table 5). Finally, pediatricians in the East refer some conditions more often than their colleagues in other parts of the country: hematemesis, idiopathic thrombocytopenic purpura in a 5-year-old, encopresis in a 6-year-old, nonfebrile seizure, attention deficit hyperactivity disorder, and a 12-year-old with knee pain after a fall on the baseball field.




Where the referrals go

We asked pediatricians to what five subspecialties they most often made referrals. Orthopedics topped the list, followed by dermatology, allergy, cardiology, and neurology (Table 6). Referrals less often went to gastroenterology, nephrology, pulmonology, psychiatry, or another mental health professionals.



Pediatricians are on the receiving end of referrals as well, of course. Most referrals come from general or family practitioners, followed closely by obstetricians/
gynecologists (Table 7). Most pediatricians (70%) believe that the number of patient referrals they receive from other physicians has not changed in the last three years; 16% note an increase and 14% a decrease. Seven of 10 pediatricians receive at least one patient through physician referral each month. Pediatricians who practice in urban and suburban areas average more referred patients a month than those who are from rural areas.



Today's pediatric practice

About half of respondents are in a group practice of three or more physicians, almost two thirds of which are solely of pediatricians. Other pediatricians practice alone (16%), are in a partnership (10%), on the staff of a hospital (9%), or in a staff model HMO (6%). More than one-third are salaried employees of an MCO or group practice. A full 81% of respondents contract with at least one MCO—and the mean is nine. Pediatricians in urban and suburban areas contract with significantly more managed care organizations than their colleagues in rural areas. About 37% of pediatricians reported that 50% to 70% of their patients belong to MCOs and another 31% said the percentage was even higher; fewer than 15% said that 20% or fewer of their patients were enrolled in managed care plans. Pediatricians in urban and suburban areas report having significantly more patients in MCOs than those in rural areas. On average, pediatricians report that 56% of their patients are enrolled in managed care plans.

Six of 10 pediatricians who contract with MCOs believe that the increase in managed care during the past 10 years has not influenced their referrals to subspecialists. Of the four in 10 pediatricians who think that the prevalence of MCOs has influenced their referrals, 50% believe they make fewer referrals, while 12% think they make more. Three of 10 pediatricians say that the MCOs with which they contract offer financial incentives to minimize patient referrals. About six in 10 take into consideration the managed care plan the patient subscribes to when they consider making a referral. About a third of respondents report that their MCOs follow quotas or yearly guidelines for patient referrals.

More than a third of respondents responded Yes to the question, "Has referring patients to another physician ever resulted in your loss of those patients." Those who answered Yes lose an average of 5% of referred patients. On average, pediatricians who are in an HMO or practice alone report losing a higher percentage of referred patients to another physician than pediatricians in group practices.

Adding it up

Results of our survey show that managed care has not had the chilling effect on referrals that many observers expected. The statement United Health Group, a leading HMO, made when it announced in November that it will no longer require a doctor to seek its approval before making a referral or otherwise deciding what care is medically necessary, suggests one reason why. The HMO said that before implementing the new policy it already approved nine out of 10 care decisions.4 Another factor may be that only a minority of pediatricians, according to our survey, belong to MCOs that provide financial incentives to minimize patient referrals. Finally, pediatricians may be highly subject to what one study of family physicians and consultants targeted as the most important nonmedical influence on referrals: patient (that is, parental) pressure.5


1. Medical Economics 1999 Continuing Survey (unpublished)

2. The pattern of pediatric referrals. Contemporary Pediatrics 1988;5(12):20

3. Forrest CB, Reid RJ: Passing the baton: HMOs' influence on referrals to specialty care. Health Affairs 1997; 16(6):157

4. Freudenheim M: Big HMO to give decisions on care back to doctors. New York Times November 9, 1999, page 1

5. Langley GR, MacLellan AM, Sutherland HJ, et al: Effect of nonmedical factors on family physicians' decisions about referral for consultation. CMAJ 1999;147(5):659


Marian Freedman. Pediatric referrals on the (surprise!) upswing. Contemporary Pediatrics 2000;2:97.

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