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More than half of PCPs give unneeded referrals upon patient request

Many primary care physicians reported acquiescing to patient requests for unnecessary care, including unneeded specialty referrals and prescriptions for brand-name drugs when equivalent generics were available, according to a study published in American Journal of Managed Care.

“Currently, 30% of annual health care expenditures in the United States are believed to be unnecessary, including but not limited to avoidable hospitalizations, unnecessary procedures and testing and poor prescribing practices,” Sapna Kaul, PhD, MA, assistant professor of health economics at the University of Texas Medical Branch in Galveston, and colleagues wrote. “Patients influence some of this spending by asking physicians for unnecessary medical services.”

To understand how physician responses to patient requests affect unnecessary medical practices, the researchers evaluated two such practices: Unneeded specialty referrals and brand-name prescriptions when generic alternatives are available.  They used data from the 2009 National Survey on Medical Professionalism (NSMP), limiting their focus to the 840 PCPs who responded. Of these, 23.5% were general pediatricians, 32.8% practiced family medicine and 43.7% practiced internal medicine.

The researchers examined responses to two survey questions: “In the last year, how often have you given a patient a referral to a specialist because the patient wanted it when you believed it was not indicated?” and “In the last year, how often have you prescribed a brand-name drug when an equivalent generic was available because the patient asked for the brand-name drug specifically?” Possible responses were “never,” “rarely,” “sometimes” or “often.”

According to the researchers, 51.9% of PCPs reported sometimes or often providing unnecessary specialty referrals, and only 10.6% indicated they never gave such a referral in the last year. In addition, 38.7% reported sometimes or often prescribing brand-name drugs when equivalent generics were available. Across specialties, 43.3% of pediatricians reported sometimes or often referring patients to a specialist unnecessarily, compared with 56.2% of family practice physicians and 53.3% of internal medicine physicians. Likewise, 18% pediatricians reported of sometimes or often prescribing brand-name drugs, compared with 38.7% of family practitioners and 49.8% or general internists. Other predictors of giving in to patient requests included meetings with drug or service company representatives, more years of clinical experience, seeing fewer uninsured or Medicaid-insured patients, and solo or 2-person practice organizations.

“Overall, we found that PCPs commonly acquiesce to patient requests for unnecessary referrals to specialists and for brand-name drug prescriptions, and several physician characteristics predicted this behavior,” Kaul and colleagues wrote. “Ideally, the enormous natural experiment underway in the United States involving combinations of physician- and patient-level incentives will illuminate the solutions to the unnecessary medical practices out study reveals.” – by Jason Laday

Disclosure: Kaul reports a family member who is employed with Humana. The remaining authors report no relevant financial disclosures.