Journal of General Internal Medicine

, Volume 15, Issue 3, pp 163–168

Why do physicians vary so widely in their referral rates?

  • Peter Franks
  • Geoffrey C. Williams
  • Jack Zwanziger
  • Cathleen Mooney
  • Melony Sorbero
Original Articles

Abstract

OBJECTIVE: To determine which physician practice and psychological factors contribute to observed variation in primary care physicians’ referral rates.

DESIGN: Cross-sectional questionnaire-based survey and analysis of claims database.

SETTING: A large managed care organization in the Rochester, NY, metropolitan area.

PARTICIPANTS: Internists and family physicians.

MEASUREMENTS AND MAIN RESULTS: Patient referral status (referred or not) was derived from the 1995 claims database of the managed care organization. The claims data were also used to generate a predicted risk of referral based on patient age, gender, and case mix. A physician survey completed by a sample of 182 of the physicians (66% of those eligible) included items on their practice and validated psychological scales on anxiety from uncertainty, risk aversiveness, fear of malpractice, satisfaction with practice, autonomous and controlled motivation for referrals and test ordering, and psychosocial beliefs. The relation between the risk of referral and the physician practice and psychological factors was examined using logistic regression. After adjustment for predicted risk of referral (case mix), patients were more likely to be referred if their physician was female, had more years in practice, was an internist, and used a narrower range of diagnoses (a higher Herfindahl index, also derived from the claims data). Of the psychological factors, only greater psychosocial orientation and malpractice fear was associated with greater likelihood of referral. When the physician practice factors were excluded from the analysis, risk aversion was positively associated with referral likelihood.

CONCLUSIONS: Most of the explainable variation in referral likelihood was accounted for by patient and physician practice factors like case mix, physician gender, years in practice, speciality, and the Herfindahl index. Relatively little variation was explained by any of the examined physician psychological factors.

Key words

Primary health care physician’s practice paterns referral and consultation 

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Copyright information

© Society of General Internal Medicine 2000

Authors and Affiliations

  • Peter Franks
    • 1
  • Geoffrey C. Williams
    • 2
  • Jack Zwanziger
    • 3
  • Cathleen Mooney
    • 3
  • Melony Sorbero
    • 3
  1. 1.the Primary Institute, Department of Family MedicineUniversity of RochesterRochester
  2. 2.Departments of Medicine and Clinical and Social Sciences in PsychologyUniversity of RochesterRochester
  3. 3.Department of Community and Preventive MedicineUniversity of RochesterRochester
  4. 4.Dept. of Family MedicineUniversity of RochesterRochester

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