Why do physicians vary so widely in their referral rates?
OBJECTIVE
To determine which physician practice and psychological factors contribute to observed variation in primary care physicians' referral rates.


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


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


METHODS
Internists and family physicians.


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 psycho-social 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, specialty, and the Herfindahl index. Relatively little variation was explained by any of the examined physician psychological factors.
Franks
P
P
Primary Care Institute, Department of Family Medicine, University of Rochester, Rochester, NY, USA. peter_franks@urmc.rochester.edu
Williams
G C
GC
Zwanziger
J
J
Mooney
C
C
Sorbero
M
M
D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007345:Insurance Claim Review; D008297:Male; D008329:Managed Care Programs / Q000592:standards / Q000706:statistics & numerical data*; D008875:Middle Aged; D009518:New York; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000592:standards* / Q000706:statistics & numerical data*; D012307:Risk Factors; D011795:Surveys and Questionnaires