Doctor Referral

December 17, 2007 6:50 AM

What is the logic in insurance companies requiring referrals from a primary care physician when you go to a specialist?
posted by josher71 to health & fitness (26 comments total)

They believe that fewer patients will actually see specialists, who are more expensive for the insurance compabies. In many cases, they even keep statistics on which primary care physicians refer patients to specialists at high rates. Presumably they do so to discourage such behavior.
posted by Lame_username at 6:52 AM on December 17, 2007

Visiting a specialist is more expensive. Your PCP acts as a gatekeeper, preventing you from incurring an expensive specialist visit when it is unwarranted. Additionally, the added hassle of having to see a PCP first will prevent some from seeking medical care for minor complaints. It also justifies reduced reimbursements when you decide to see a specialist without a referral.
posted by grouse at 6:54 AM on December 17, 2007

Specialists also tend to do lots of tests automatically. Like try to see an orthopedic surgeon who doesn't do X-rays ("just in case"), or a urologist who doesn't do a urine test. Insurance companies don't like paying for tests.
posted by smackfu at 6:55 AM on December 17, 2007

Also, incidentally, my PPO doesn't require referrals to see a specialist. Presumably it's an option on the insurance plan, that most employers don't choose.
posted by smackfu at 7:01 AM on December 17, 2007

There is no logic. It just saves them money.

All hail Japanese universal insurance: x-rays cost $15, specialist requires nothing extra, taxes are lower than the U.S.

Someone got it right; it isn't Canada.
posted by fan_of_all_things_small at 7:09 AM on December 17, 2007

There is no logic. It just saves them money.

Uh, that is the logic.
posted by grouse at 7:16 AM on December 17, 2007

Yes - the logic is the savings for the insurance company. It increases your opportunity costs for going - you have to go twice. So it means you're less likely to go.
posted by Pants! at 7:18 AM on December 17, 2007

The insurance companies are afraid that if they didn't have the PCP around to act as a gatekeeper, people would run off to expensive specialists willy-nilly for every minor complaint. Whether this is a valid fear or not is debatable, but that's the root of it: they don't trust patients to make the decision as to whether they need a specialist or just a GP. So they make you go to the GP first, and have them decide whether it's a valid reason to bump it up to a specialist.
posted by Kadin2048 at 7:20 AM on December 17, 2007

My PPO doesn't require it, but I still use my primary physician as my guide for who to see. It's much easier to get an appointment with a doc's recommendation (by the time I need a specialist I usually need a quicker one). Also, if you have something that falls into multiple categories of possibility then it can be really helpful to have someone that will point you in the next direction when specialist 1 tells you everything is fine. My doc also reminds me when I need to go see specialist X again, which I'm not so good at.
posted by ejaned8 at 7:21 AM on December 17, 2007

While requiring a referral IS motivated by profit, it does make a certain amount of sense. I can see where there are probably many people out there who would simply head to specialist for any ache and pain, in essence self-diagnosing. Requiring your PCP to act as gate-keeper is a reasonable requirement (said by someone who, in general, is highly critical of most insurance company practices)
Point-of-fact, many specialists don't take new patients without a referral anyway.
posted by Thorzdad at 7:21 AM on December 17, 2007

Logic pertaining to the insured, not pertaining to the insurance company.

Logic that saves an insurance company money defeats the purpose of health insurance. Unless you work for an insurance company.

The human body is not a marketable commodity.
posted by fan_of_all_things_small at 7:25 AM on December 17, 2007

Because a primary care physician is qualified to identify the correct specialist, you are not.

Self-diagnosing a running off to any specialist you please wastes a lot of time and time = money. Your insurance company isn't going to want to pay for you to go to an expensive specialist for something your GP is more than capable of diagnosing and treating.

I'm on the NHS, no insurance companies pulling the strings - you still need to see your GP to get a referral. (Even most people with private medical insurance go to see their NHS GP first)
posted by missmagenta at 7:30 AM on December 17, 2007

For example:

Jane Doe has a really bad headache almost every day. The more she thinks about it, the more she remembers her friend Karl's Aunt Jemimah who had a headache and it turned out it was a giant brain eating tumor the size of a country apple, and Jemimah was cold in the ground before Christmas. Jane, free from the requirement to get a referral from a physician, hauls her butt into the nearest oncologists office, and demands $15,000 worth of diagnositc tests to rule out a brain tumor. They find NOTHING, and start telling Jane about other things that could be causing her headaches. Jane, picking up on one of the suggestions, goes to an allergist and confesses that she got a puppy for the first time three weeks ago, and has been sneezing ever since while rushing home from work every day to feed and houstrain her new friend. After a simple allergy test, it turns out Jane is allergic to dogs. After 2 weeks of generic allergy medication, Jane is headache free. (*)

The moral of the story is that any decent PCP could have talked with Jane for 15 minutes and figured this out, thus saving the insurance company $15,000. Many people, myself included, believe that to at least SOME degree that saves ME money, since the insurance company will pass on higher claims costs to me in the form of raising premiums.

(*) This is a dramatization, overly simplified to prove a point. All names have been changed to protect the innocent. Any similarity to any real person, alive or dead, is purely accidental.
posted by bunnycup at 7:56 AM on December 17, 2007

Logic pertaining to the insured, not pertaining to the insurance company.

OK, it saves the insured money too, as bunnycup points out. If you don't want a plan with this requirement, you can find one, but it will cost you more.
posted by grouse at 8:07 AM on December 17, 2007

Logic pertaining to the insured, not pertaining to the insurance company.

In my example, during the time Jane spent barking up the wrong tree worrying about a tumor, she was needlessly prolonging finding the RIGHT CURE for her headaches. If it took 6 weeks to get an appointment with the oncologist and 2 weeks for the cancer tests to come back, that is 8 weeks of near-daily suffering she could have avoided by having a PCP identify the CORRECT specialist, obtain an appointment sooner(*) and obtain correct treatment promptly.

In my example, its a matter of convenience and dealing with annoying headaches. But what if Jane's problem wasn't allergies, but instead symptomatic of severly worsening heart disease, or the aftermath of a stroke? Being referred to the CORRECT specialist earlier in the process could SAVE THE INSURED'S LIFE, quality of life, pain and suffering, and so forth.

(*) My PCP had obtained a same day appointment with a specialist for me. When I called that specialist back for a 2nd appointment, there was a 6-week wait.
posted by bunnycup at 8:32 AM on December 17, 2007

Ironically Specialists that initially hated the thought of PCP's controlling referrals have now come full circle and won't even schedule a patient if they aren't first referred, and not just because of the risk of not getting paid. It drastically cuts down the number of nonsense visits and frees up the specialist for truly complex cases.
posted by docpops at 8:33 AM on December 17, 2007

Because a primary care physician is qualified to identify the correct specialist, you are not.

It just depends on the circumstances. I think that there are many situations where a person could easily self-refer to a gynecologist or a psychiatrist or a podiatrist or an obstetrician. There are also cases that are something of a dilemma like a teenager with acne. The PCP may feel that they can perfectly adequately treat it and consider that the condition is under adequate control when the patient would prefer a dermatologist who is likely to be best informed in all available treatments and options. What is right in that case?

The story of the patient who self-diagnoses as brain tumor and somehow gets an oncologist to run every test in the book is something of a straw man. I don't doubt that some people would abuse the system by running to specialists that aren't needed, but that doesn't mean that no one should be permit to make their own referral.
posted by Lame_username at 8:38 AM on December 17, 2007

Sure, Lame_username - but is the person who self-refers to a psychiatrist qualified to rule out thyroid function and any of the plethora of physical causes that most PCPs will consider seriously prior to making the referral for (costly) psychiatric care? Also, a few minutes with a dictionary and the words "metaphor," "analogy," and "parable" might serve you well.

MANY people are not capable of correctly identifying the medical cause for their symptoms. Believe it or not, the majority of the world seems to feel specific education and training is needed in order to do that. A shocker, I know.

YMMV, but my insurance doesn't consider OB/Gyns a "specialist" - most woman are free to see them at will, and in fact have "primary ob/gyn" doctors that serve in a corrollary capacity, i.e. as the main caregiver for such medical needs and the gatekeeper to specialists. I believe that to be typical, but you clearly feel your experience as an apparently childless male is more telling.
posted by bunnycup at 9:15 AM on December 17, 2007

I believe that to be typical, but you clearly feel your experience as an apparently childless male is more telling.

Wow. Nice.

What is the logic in insurance companies requiring referrals from a primary care physician when you go to a specialist?

To add another level of red tape and as a barrier to getting the care you need. It's a ruse to give you the impression that since you PCP ok'ed it, well then, "it must be ok and I'm covered!" Sadly your PCP nor the specialist have much say in whether something gets covered. You can read your manual from cover to cover, have it memorized and it still does not matter. It only matters to the UR people who Look At Paperwork in the home office and who are trained to pour over claims to specifically look for ways to cut costs which simply means denying claims. I've worked on both ends of this and for anyone to believe otherwise is foolish. The fuckery that happens behind the scenes is astounding and caused me many sleepless nights which is why I got out of the business in the first place.

So to summarize, you have to deal with the PCP first, do the little dance and pray for the best. I wish you well.

Jes/Cortex/Matt - Feel free to delete. I promise I won't start a MetaTalk thread.
posted by KevinSkomsvold at 9:40 AM on December 17, 2007

Everything insurance companies do, they do to maximize profit. While there may be some benefit to you as well--in terms of 'forcing' you to see the appropriate specialist--they don't care about that. They are in it for the money. The reason they make you get a referral is, as other have said, that you are somewhat less likely to go through the hassle, and put off going to the specialist indefinitely, particularly for problems that are not painful or life threatening. I really should go see a dermatologist for this annoying skin condition I have, but I looked it up online, I know it's not a serious problem, and I keep forgetting to ask my PCP for a referral. If I could just call a dermatologist up while I was thinking about it, I would have already gone. But I can't, so I haven't bothered. My lack of patience with red-tape=less money paid out by my insurance company. I doubt I'm the only one in that situation.

Also--an added hoop to jump through gives them another reason to deny claims, which is more good news for the bottom line.

As a general rule, the answer to why insurance companies do anything will always be some variation on "to make more money or spend less money."
posted by Pater Aletheias at 10:26 AM on December 17, 2007

Also, a few minutes with a dictionary and the words "metaphor," "analogy," and "parable" might serve you well.

Pretty condescending, don't you think? If you going to resort to that kind of ad hominem argument, you should probably decide which of the three you think your story actually was. I suspect you will find that at least two of them aren't appropriate at all. Maybe you wanted hyperbole?

YMMV, but my insurance doesn't consider OB/Gyns a "specialist" - most woman are free to see them at will, and in fact have "primary ob/gyn" doctors that serve in a corrollary capacity, i.e. as the main caregiver for such medical needs and the gatekeeper to specialists. I believe that to be typical, but you clearly feel your experience as an apparently childless male is more telling.

Your insurance may well allow you see them at will, but I'm quite sure they still consider them a specialist. They just accept that people are capable of self-referral in that case. Not all HMOs do this, for your information. Some HMOs that permit self-referral to OB/GYN specialists for annual exams still require approval from the gateway PCP for any other treatment (see this HMO for an example). When HMOs were new, they often tried very hard to get women to get their annual exams from their PCP and there was a great deal of push-back. I appreciate your interest in my private life and I am indeed a childless male, but this is not the source of any knowledge I might have. I do participate in the review and selection of HMOs for a fairly large company and have seen a great many different insurance plans as a result. I have also listened to a great many complaints from employees when they were having trouble with the referral process.

For the record, I do not dispute that people do not always have the expertise to diagnose their own symptoms. I simply think that there are some situations where they can and that most people would have sense enough to go to an appropriate diagnostician when they could not. In the worst case, they would go to a specialist who would send them on their way. Somehow millions of people in PPOs or traditional insurance manage to do this.
posted by Lame_username at 11:02 AM on December 17, 2007

A side benefit to you as the patient is that your specialist is less busy, so you should be able to get an appointment faster.
posted by smackfu at 11:08 AM on December 17, 2007

I suspect you will find that at least two of them aren't appropriate at all. Maybe you wanted hyperbole?

Nope, I'm CERTAIN that I wanted parable, actually, but it sounded like you could benefit from review a whole plethora of words that indicated concepts being used rhetorically. Maybe you need your basic dictionary to give you a referral to one for grown ups. And frankly, I don't think I was NEARLY condescending ENOUGH, and I'll be wary of that in future.

For the record, I do not dispute that people do not always have the expertise to diagnose their own symptoms. I simply think that there are some situations where they can and that most people would have sense enough to go to an appropriate diagnostician when they could not.

Hmm, so what you're suggesting is that in some areas (already addresses in most insurance rules), patients can determine that a pain in their vagina requires a vagina doctor. That these examples, such as your theoretical patient with a headache who is actually remotely LIKELY to select whether they need cardiac care, circulatory care, allergy management, oncology, glasses, infectious disease control (could be yellow fever!) or what have you, should be free to self-select. I assure you, this is the gross minority by far, whatever your HMO selection experience leads you to believe.

But, in our current profiteering system, prior to seeing an expensive specialist who may or may not be one of the tens to hundreds of varieties of doctors that cover the particular as-yet-unidentified problem with which the patient presents, the patient FIRST reviews their symptoms with a doctor knowledgeable about their background, history, and other medical issues who might be able to cut out some of the waste of time, money, needless suffering, potentially fatal delay in diagnosis, etc. Whoo, good point, that's AWFUL.

Talk to the families of one of my clients who died because of a delay in diagnosis of cancer or heart disease. Or a good friend of mine whose father died after ignoring a sore throat for a month thinking it was just a cold, when it was in fact cancer that killed him within 6 months. Why don'y you tell them how good at self-diagnosis people are?

Of course this saves money for the insurance company. Believe it or not, sometimes (I'm not saying always) a policy is both cost-controlling, efficient and wise, all at the same time. Most aren't, for sure, and some probably find that confusing, however this is an area where in most situations the patient is HELPED by speaking with a primary care provider prior to setting a course for all and sundry potentially unnecessary specialist appointments. That that SAME insured patient keeps their already skyrocketing medical costs a little lower, should be icing for them. I know I wouldn't pay a penny more for the right to go get a cat scan every time my tummy hurt, without calling a doctor first.
posted by bunnycup at 11:30 AM on December 17, 2007

Nope, I'm CERTAIN that I wanted parable, actually, but it sounded like you could benefit from review a whole plethora of words that indicated concepts being used rhetorically

You consider your example a parable and I consider it a strawman. I suppose we will just have disagree. Can I use "characterized by overelaborate or bombastic rhetoric" as my definition of rhetorical?

In terms of the rest of your argument, I think where you are missing my point is when you suggest that I am in favor of self-diagnosis instead of using trained medical personnel. Nothing could be farther from the truth. I merely believe that people should have the choice to seek help in the manner of their choosing. If they know what sort of specialist they need, they should be able to see them. If they need help sorting that out (which should be the overwhelming majority of the time), they should be able to go to their PCP. What I am opposed to is an arbitrary ruling that they must always get permission from one doctor to see another.

I'm sorry about the deaths of those that you know. However, someone who ignores their symptoms does not benefit from a gatekeeper HMO. This is another strawman -- the question is not if people should do their own diagnosis exclusively, but rather if they should be permitted to see a specialist when they think it is best. I personally nearly died from a ruptured appendix which was misdiagnosed by my PCP on three consecutive visits. When he sent me home for the third time, I decided to ignore him and consulted a specialist on my own, who probably saved my life. However, such argument from anecdote is not an effective way to determine what is best for all patients.

I'm completely outside my field now, but a quick review of the scientific literature suggests that the medical profession isn't sure either. For instance, a review of delays in diagnosing childhood cancers says "physician-caused delays tended to be longer than those caused by parental or patient recognition of disease. Overall, studies showed that delays were related to several expected factors. First, evidence suggests that a government-sponsored healthcare system, dependent on primary care physicians to triage and refer, may introduce delays, at least for central nervous system cancers." (emphasis mine -- source "Diagnosis Delays in Childhood Cancer: A Review," Tam Dang-Tan, Eduardo L. Franco, Cancer; Published Online: July 9, 2007 (DOI: 10.1002/cncr. 22849); Print Issue Date: August 15, 2007.)
posted by Lame_username at 12:12 PM on December 17, 2007

Lame_username, any patient is welcome to self-refer to a specialist when they think it's best. The insurance company simply has not offered to reimburse for such self-referrals. As a consumer, as an insured on a health insurance plan that costs hundreds of dollars a month, I don't want them to. But if they feel strongly that their PCP is wrong about the headache then by all means go to the oncologist if you're sure that's it - and then go to the allergist - and then to the cardiologist - and then get your vision tested - and then see a therapist to reduce stress headaches - and then see a nutritionist for a vitamin deficiency - and so on. By focusing on uniquely simple examples such as appendecitis, the signs and sympotms of which are discrete, well known and identifiable, you're attempting to imply that MOST medical decisions are quite this simple. The facts that the referral system (involuntary as required by insurance companies and voluntary, as I discuss below) is common, that most medicines require a prescription to obtain (i.e. we feel that self-diagnosis and self-treatment is commonly inaccurate and dangerous), that when truly ill we DO seek a doctor rather than follow our own judgment (as my friend's Dad should have done, for sure), the fact that years and years and years of education and training are required to be a doctor and I guarantee you wouldn't want it any other way, should all lead you to believe that laymen are NOT, ON AVERAGE, QUALIFIED TO SELF-DIAGNOSE AND SELF-SELECT A SPECIALIST. The rule should reflect the average, the common, the repeat scenario, the norm - and I posit it does.

I agree that anecdotes should not be the basis for policy formation, particularly because any anecdotes are set against a background where most individuals simply do obtain referrals (whether by force or necessity - I asked a PCP who I should select as an OB when I moved to a brand new town while pregnant not because I needed to, but because I wanted a good doctor and a prompt appointment. I'll probably ask my PCP and my OB who they would suggest as a pediatrician for the kid once born - this isn't the "referral system" villified in this question, or a gatekeeper processes, but it illustrates a common way many people find a specialist). If the referral system was taken away and people COULD afford to willynilly show up at oncologists offices complaining about brain tumors - or if for every medical AskMe there was a resulting trip to the specialist suggested by the majority of The Hive - I strongly, STRONGLY believe there would be WORSE medicine for most people, compared to the current system.

Finally, I think it's widely commented that "government-sponsored healthcare" is rife with delay that does not exist in the same manner in privatized healthcare. Thus, I don't think your comparison is particularly convincing. Show me a study that says the referral system in privatized healthcare introduces delays (that overall negatively impact patient care), and I'll be more persuaded - and believe me, I bet that study exists. However, I haven't said referrals don't lead to some delay - simply that the delay in ULTIMATE accurate diagnosis and treatment for a patient who endeavors, trial and error, to self-diagnose sufficient to select among various specialists, would overall have a stronger negative effect (for the individual patient, health and cost-wise, for other insureds, health and cost-wise, and for the insurance company, cost-wise)
posted by bunnycup at 12:39 PM on December 17, 2007

[bunnycup/lame_username, please take this to mefimail, you are not helping to OP and you're derailing this thread. thank you.]
posted by jessamyn at 1:05 PM on December 17, 2007