title: Study of self-referral factors in the three-level healthcare delivery system, Kashan, Iran, 2000.
abstract: BACKGROUND
  In any healthcare system an appropriate structure is essential to operational efficiency. Patients must be able to easily access healthcare workers and/or health centers in their own community. In the first contact with a healthcare practitioner, particularly if that contact is with a GP, 90% of patient needs can be met. If the initial problem cannot be managed, the decision will be made to refer the patient to a specialist. Except in an emergency, all patients should be seen first by a primary healthcare physician who decides whether a referral to secondary care is necessary. This avoids system inefficiencies such as disadvantaged groups suffering from lack of specialist care due to specialist doctors being overwhelmed by the inappropriate self-referrals. In the Kashan region, Islamic Republic of Iran, patients can be classified according to their type of health insurance, which dictates the type of specialist referral available: (1) Closed-loop referral (Imam-Khomeini Welfare Committee); (2) Semi-closed-loop referral (Rural Health System Insurance); and (3) Open referral (social security insurance, therapeutic services insurance, self-insured [private] and the non-insured). The organisation of the Iranian health system has been proposed by WHO as a model for other communities. The present study examined patterns of patient self-referral direct to specialist according to health insurance system in the rural Kashan region, and established the reasons for patient self-referral to specialists.
  
  
  METHODS
  A random sample of 1036 individuals was selected from people attending public outpatient clinics and specialists' offices in the private health sector. Of the sample, 413 (40%) were insured by the Imam-Khomeini Welfare Committee (closed loop referral); 145 (14%) by rural health system insurance (semi-closed-loop referral); and 478 (46%) were covered by social security or therapeutic services insurance, out of pocket and other cost payment procedures (open referral). The subjects were interviewed individually in the waiting room by means of a questionnaire before or after their specialist visit. The self-referral rate in the triple insurance structure was calculated. The data were analyzed using a chi2 statistical test.
  
  
  RESULTS
  Of the closed-loop referral system patients, 6.8% were self-referred, as were 29.7% of semi-closed referral system patients and 75.5% of open referral system patients (chi2 = 504; p <0.0001). The self-referral rate to the public sector was 60.5%, while to the private sector it was 36.4%, (chi2 = 449; p <0.001). The main reason patients gave for by-passing GPs and self-referring to specialists were: the specialist's high degree of skill in the specific area of the health problem (54%); waste of time to see the GP for a referral (14.9%); and that the patient's information about the referral system was poor (10.5%).
  
  
  CONCLUSIONS
  The findings of this small study demonstrate the high degree of difference in the rates of referral by GP and self-referral according to the healthcare delivery system structure (insurance type and sector). The universal availability of health insurance may be one of the reasons for the similar health status of rural and urban populations in Iran. The findings may be regarded as preliminary to further research into this area of health system design.
authors.affiliation: Kashan University of Medical Sciences, Kashan, Iran. ras_38047@yahoo.com
authors.forename: S
authors.initials: S
authors.lastname: Rasoulynejad