Patient referrals: a linchpin for increasing the value of care.

The success of accountable care organizations (ACOs) under global payment may depend in part on a common yet poorly understood clinical decision: the patient referral in the outpatient setting. Fundamental to collaboration among physicians and other health care professionals, patient referrals have been largely ignored in the payment reform debate. Referral rates intheUnitedStatesmorethandoubled from 1999 to 2009,with about 10%of outpatient visits resulting in a consultation or visit to another physician.1 Referrals seemtobebothunderusedandoverused,with clinical informationoftenpoorlytransferredbetweenphysiciansandfrequentconfusionbetweenprimarycarephysicians and specialists over the specialist’s role.2 Yet little isknownaboutreferrals.Bysystematicallymeasuringand evaluatingreferrals intheirphysiciannetworks,ACOsmay beable tobetter targetefforts to improvecarecoordination and reduce spending. Referrals may be driven by a number of factors. Physician knowledge gaps due to specialization create a natural demand for referrals. Time pressures on outpatient clinicians may intensify this demand, because