We found that the majority of patients with a specialist visit in the past 12 months report less than ideal coordination between their PCP and the specialist. Continuity of visits with the same PCP and PCP as referral source were each independently associated with higher ratings of care coordination. Among persons with chronic conditions, the association between PCP as referral source and each of the three coordination outcomes was even more pronounced.
Continuity of visits with the same clinician has been linked with better coordination in a pediatric population.25
Our finding that visit continuity with the same PCP was associated with better coordination for adults adds to this prior work among children.
Assessment of additional factors associated with better coordination between primary care and specialist physicians in the literature to date comes predominantly from physician surveys and chart reviews. Such data revealed that improvements in the referral process and its completion, as well as physician satisfaction with the referral process, result from the PCP making the appointment with the specialist, the PCP sending the specialist information about the referral, and the specialist providing feedback to the PCP that include plans for co-management.7
A survey of PCPs and their patients identified continuous telephone access, the presence of agreements with other health care providers, and the performance of more services within the PC office as being associated with higher levels of coordination between PCPs and specialists.22
To this prior work, we add the finding that coordination of care between PCP and specialists is much better, from the patient perspective, when the PCP is the referral source.
Rates of patient self-referral vary with patient age, insurance, local market factors, and health status. Among persons under age 65 in three points of service plans, self-referral rates were on the order of 17% to 30%.26
Among Medicare beneficiaries, self-referral rates are much higher, with some estimates of patient self-referrals to specialists as high at 70%.27
Despite the prevalence of self-referral, patients do not always feel that they have the awareness of when a referral is clinically indicated or appropriate. Patients value the first contact and coordination roles of PCPs, and find PCP participation helpful in deciding to see a specialist.30
Given the high rates of self-referral, associated fragmentation of care, and associated costs of greater use of specialists,28
efforts to improve care coordination might take into account the benefit of having a PCP as the referral source as identified by patients in this study.
While continuity of visits with one’s PCP, and PCP as referral source, were associated with substantially higher ratings of coordination of specialist care, there is clearly room for improvement. For example, even when patients’ most recent visit to a specialist was based on PCP referral rather than self-referral, only 50% of the patients reported that the PCP was always informed about care received from the specialist. Communication between the PCP and consulting specialists likely needs to be increased from both directions, and sharing of the results of such communications with patients likely also requires additional attention. Deficiencies in consultant communication back to PCPs have been widely documented.1,11
Thus, achieving maximal coordination will likely require efforts that target specialists as well. Incentives for two-way communication are currently lacking in our fee-for-service reimbursement system, with a negative impact on coordination of care for patients.
Limitations of our study include that most measures were patient self-reported; thus, there is the potential for bias in that patients who value coordination more highly may also do more to inform their PCP of their desire to visit a specialist, or may participate more actively in organizing their care. We attempted to control for this potential bias by including a validated measure of how much patients actively participate in their own care.23
It is also possible that patient’s may over-estimate the extent of coordination by their providers. In an attempt to adjust for the “coordination burden” a patient might require, we adjusted for the number of chronic conditions, the patient’s health status, and whether s/he saw more than one specialist in the past 12 months. However, we were not able to adjust for the total number of visits to specialists in the past 12 months because we do not have access to respondents’ claims data, and, patient recall of the annual number of visits by provider type has been demonstrated by others to be poor.29
Finally, these data are cross-sectional; thus, it is not possible to ascertain causality.
Decision makers want practical advice on how to improve coordination of care.2
Our nationally representative study demonstrated that coordination is better, from the patient perspective, when patients see the same PCP for most of their primary care visits and when specialist referrals are made by the PCP rather than by another means.
Our findings can help inform current efforts to develop and finance medical homes by taking into account the roles that visit continuity with the same PCP and PCP as the referral source have on better coordination of care as rated by patients. This information can inform efforts to create educational messages for patients, and incentives for patients and providers. Patients can be encouraged to see the same PCP for as many of their visits as possible, when scheduling and access needs permit; provider appointment and scheduling systems can be structured in a way to facilitate this.
Patients can also be engaged in a discussion or voluntary agreement with their PCP about the benefits of having a PCP as their coordinator and referral source, as opposed to engaging in self-referrals or cross-referrals from one specialist to another. On the specialist side, specialists might be encouraged by payers to both communicate back to a patient’s PCP and to inform a patient’s PCP of cross-referrals they make. Encouraging patients to obtain referrals to specialists from their PCPs need not necessarily take the form of mandatory gate-keeping. A study of point-of-service health plan enrollees found that simply having the option to self-refer was enough for enrollees.26
Thus, encouraging patients and physicians to voluntarily coordinate referrals within the medical home (rather than imposed gate-keeping) may be sufficient to enhance coordination of care.
Finally, our findings have implications for efforts to foster health care “consumerism”–broadly defined as consumers taking more responsibility for medical costs, lifestyle choices, and treatment decisions. Some observers propose financial incentives for consumers to “shop” for physicians and hospitals through the use of comparative cost and quality information. An unintended consequence of increased “shopping” for physicians could be an increase in self-referrals to specialists by patients who want to avoid the cost of a primary care visit. Others have found that patients do not always feel that they have the awareness of when a referral is indicated, and they find PCP participation helpful in deciding whether to see a specialist.30
Thus, efforts to engage patients in consumerism might consider our findings that patients perceive their coordination to be better when they have continuity of care with the same PCP and when their referrals to specialists were based on PCP recommendation.