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If you're losing patients to specialists. . .


Have you referred patients to consultants, never to see them again? Here's why it happens, and how to prevent it.


If you're losing patients to specialists . . .

Jump to:
Choose article section... The decline of capitation and the gatekeeper role How some physicians hold onto their patients

Have you referred patients to consultants, never to see them again? Here's why it happens, and how to prevent it.

By Berkeley Rice
Senior Editor


Many primary care physicians have long complained that specialists don't "return" their patients after a referral. Lately, some say, it's happening more than it used to.

Few go so far as to accuse specialists of "stealing" their patients. But a number of primary care doctors tell us they've been hurt financially. So we talked to members of our Editorial Board and our editorial consultants to find out what the situation is like in their neck of the woods and what techniques they'd suggest for hanging on to patients.

Richard Waltman, an FP in Tacoma, WA, says he's definitely lost patients to specialists, and he's convinced that their motivation is mainly financial. "When I first came to town, the specialists were so busy that they always sent our patients back to us. But two things have changed since then: First, the specialists are no longer as busy. Second, they all have nurse practitioners and physician assistants now, and they need to keep these people busy to increase their own incomes.

"I still manage to keep most of my patients," says Waltman. "But some of the younger members of our group are having more trouble. They may send a patient for a one-time cardiac consult, only to have the cardiologist—or more likely one of his NPs—take over the ongoing care of uncomplicated hypertension."

The decline of capitation and the gatekeeper role

Internist Mary Anne Bauman from Oklahoma City feels that the decline of capitation has led to the loss of some patients. "One of the things I loved about capitation," she says, "was that it forced both patients and specialists to allow the primary care doctor to oversee the patient's care. It made for great continuity of care, and our patients were the beneficiaries.

"With the demise of capitated care, patients and doctors are reverting back to the episodic pattern where they see one doctor for heart problems, another for lung problems, and another for arthritis," says Bauman. "The trouble is that none of those doctors knows what the other is doing, so there's less coordination of care. I hate it when a patient comes in for an annual exam and I discover that she's had breast cancer and a heart attack, and I wasn't even aware or involved."

For Bauman, the trend to self-referral has had a definite impact on practice income "since we're losing not only the office visits, but also the ancillaries, which generally make up at least 30 percent of our revenue. For example, I'm perfectly capable of doing someone's periodic cholesterol profiles, which we do in our office. But if the patient sees the cardiologist, then he's the one who does the lab work."

David C. Scroggins, a practice management consultant with Clayton L. Scroggins Associates in Cincinnati, says it's too early to tell if many patients are shifting allegiance from primary care doctors to specialists. "It might be happening in urban areas where the big insurance carriers are dominant," says Scroggins, "but it's not a big issue yet in rural areas.

"The gatekeeper concept just wasn't cost effective for the carriers," he says. "Often the requirement of an initial primary care visit before any referral turned out to be a waste of the patient's time, because the need for a specialist was obvious. But it will still take some time before the average patient changes his habits, because the HMOs have pounded the gatekeeper requirement into them for a decade."

Even a slight loss of patients, however, could mean a significant decline in practice income, says Scroggins. "Eventually primary care doctors will probably lose some visits to specialists—say 5 percent," he forecasts. "With an average of 5,000 to 6,000 patient visits a year, that would amount to 250 to 300, or a loss of $10,000 to $12,000 from the bottom line."

How some physicians hold onto their patients

"We clearly inform our patients of what we're capable of doing," says Bauman. "I tell them I want to be the coordinator of their care, so that someone knows everything that happens to them. I tell them to call me first for any problem, and if it's beyond my scope, I'll refer them to a specialist. I explain that they can get to the specialist quicker if I refer them, and that the specialist will be more likely to send the results back to me so that I can take the best care of them.

"I also ask patients who self-refer to specialists why they didn't call me first. If it was something I could have handled, I tell them. I try to set myself up as their advocate, and I try to make it convenient for them to use me first. Not everyone responds to this approach, but many do."

"What we do," says Waltman, "is to provide better service for our patients, and to maintain a close working relationship with them. We do telephone follow-ups, we call them about lab work done by specialists, we remind them of appointments, and we help them with their insurance paperwork. What I particularly enjoy is having patients ask me if they can stop seeing the specialist and just come to see us. That means we've succeeded in winning their trust."

To Roy Huntsman, a practice management consultant in Gainesville, FL, "The best way to avoid losing patients is simply to stop referring to the specialists who hang onto them. You've got to warn them: 'If you want to keep getting my referrals, just do what I send them to you for, and let me handle the rest of their general care.' That usually works."

Consultant Scroggins feels that the best way for primary care doctors to keep a close relationship with their patients is through regular preventive care and annual physicals. "But doctors first have to re-educate themselves and their patients about the value of preventive care," says Scroggins. "They need to learn about preventive codes like 99396 and 99397, which are covered by most plans. While Medicare doesn't cover routine physicals, it will pay for part of the visit when something is detected during the exam, which frequently occurs with older patients."

As for complete physicals, Scroggins feels that "the managed care mindset has discouraged primary care doctors from doing them, but patients really appreciate the time doctors take with them. Most people spend more money on dental cleanings or car maintenance than they do on preventive health care."

The most philosophical advice we heard, though, comes from Greg Hood, an internist in Lexington, KY, who says he hasn't seen any pattern of specialists stealing his patients. But, he adds, "When I do encounter patients who shop around with a variety of specialists, that's usually just their mentality. They were never really 'mine' to lose."


Berkeley Rice. If you're losing patients to specialists. . .. Medical Economics Sep. 19, 2003;80:27.

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