Preserving the patient referral process in the managed care environment

)

1

SPECIAL

ARTICLE

Preserving the Patient Referral Process in the Managed Care Environment Thomas C. Rosenthal, MD, Thomas A. Riemenschneider, MD, John Feather, PhD, Buffalo, Referrals are a central component of the American health care system, defining the relationship among generalists, patients, and specialists. The dynamics of the referral process as they existed in a fee-for-service medical environment will evolve under managed care, but retain the basic “Try-out’ approach of the generalist and “Rule-out” approach of the specialist. A managed care, contract-based health care system atters some of the assumptions on which the referral relationship has been structured. A four-step approach to assuring quality interactions among patient, generalist, and specialist within the managed care environment is described, including: (1) engage; (2) anticipate; (3) feedback; and (4) reassess. When the referral process is structured as suggested, it can be evaluated for qualii and efficacy. Armed with mutual respect and understanding, the forces that polarized specialist and generalist care in the 1980s can be redirected to enhancing patient care in the 1990s.

New York

to assure quality referrals: (1) engage; (2) anticipate; (3) feedback; and (4) reassess.

Getting

Patients

From Here to There! and Back

Forty-four percent of all patients seeing physicians have been referred. This ranges from 76%of patients seeing general surgeons to 13%of those seeing generalists.’ Generalists refer 0.5% to 15% of patients they see to other providers.2A While there is little predictability to an individual generalist’s referral rate, some trends do seem consistent.5-7 Increased referral frequencies have been reported among older, urban physicians in multispecialty practices and by physicians in generaIist practice who have had subspecialty training.8-11Insured patients with complex medical conditions are also more likely to be referred.1s12J3 In contrast, referrals are made less frequently by physicians who have greater case-specific clinical experience, who practice in m.anaged care settings, or who are graduates of non-American medical schools.11~14~15 The number of patients seen per day has little effect on referral rate, and patients with eferrals, a central component of the American common medical conditions that have well-estabhealth care system, are complicated by the oc- lished management protocols (ie, mild asthma) are casionally inconsistent perspectives of generalists, referred less often.10s13 patients, and specialists. Patients may assume that While the patient’s request for another opinion is a commonly stated reason for referral, only 4Ohof rephysicians are insensitive when breakdowns occur, but given the complex, often competitive influences ferrals are made specifically to reassure the patient incidental to the referral process, some failures are or the physician. Seventy percent of referrals request inevitable. Because rapid evolution to managed care a specific treatment, procedure, or diagnostic invesin the 1990sis shifting the generalist/patient/specialtigation; 14% request management advice; and only ist paradigm, an analysis of the structural impedi- 9% seek continued management by the specialist.‘“18 ments and external pressures affecting the referral in- Some physicians fiid referrals a convenient form of teraction is timely. The authors, representing each of continuing medical education, even indicating a prefthe participant groups, offer a “Try Out -Rule Out” erence for consultation over textbooks Ior journals.14 Model that facilitates examination of factors that In fact, the instructional quality of the specialist’s force an evolution of these relationships. Within the feedback can influence the generalist’s evaluation of framework of the model we review the literature on a referral’s effectiveness.lg referral patterns, present three views of the referral The economic impact of the more than 15 million process (generalist, patient, and specialist), examine referrals made each year in the United States is comthe impact of managed care, and propose four steps pelling. 2oA referral from a family physician to a university-based specialist generates over $5,000 (estiI I mated 1995 dollars) in combined hospital and From the Department of Family Medicine (TCR), Medicine, Primary Care professional charges, and half of all referred patients Resource Center (JF), State University of New York at Buffalo; and the will be admitted for inpatient care.21,22 Health Sciences and Hospitals, State University of New York Central Administration (TAR), Buffalo, New York. The preponderance of specialists (70% of the US Reauests for reprints should be addressed to Thomas C. Rosenthal, physician workforce) has profoundly influenced the MD, department of Family Medicine, SUNY at Buffalo, 462 Grider Street, Buffalo, New York 14215. referral process. The availability of specialists has Manuscrtpt submitted February 24, 1995 and accepted In revised form made direct referral more common, risking premaAugust 29, 1995. ture application of expensive technology originally

R

338

March

1996

The American

Journal

of Medicinea

Volume

100

PRESERVING THE PATIENT REFERRAL/ROSENTHAL

developed to benefit patients with exceptional problems.23Managed care recreates an environment in which patients, generalists, and specialists must collaborate as a team, requiring each participant to appreciate the role of the others.

Try-Outs

Symptom I

Response

Evaluation

Select

and Rule-Outs

One of the difficulties in making the referral process work effectively is that patients, generalists, and specialists employ radically different methods to arrive at a care plan. As represented in the Figure, patients have judgment elements to hurdle before deciding to present to a physician. Whether presenting to a generalist or specialist, each patient comes with a personally unique and often incompletely processed complaint shaped by their family, prior experience, fears, knowledge, and ability to articulate needs. After eliciting the chief complaint, the generalist collects historical, physical, and objective findings to arrive at a differential diagnosis. Next, in a complex cognitive process, factors such as probable/improbable, immediate danger/remote danger, resources/compliance, cost/benefit, baseline condition/potential outcome, patient/physician expectations, epidemiology/ personal experience, and refer/treat decisions converge into a “Try Out” plan. The “Try+& plan, which may include further tests, specific treatment, and/or watchful waiting, is discussed with the patient and an expected response interval is proposed. If the expected response is not achieved in the anticipated “Try Out” interval, the reasoning circle is entered again, reworked, expanded, and benefited by the knowledge acquired during the previous cycle. The patient’s confidence in, and relationship to the generalist contributes to the success or failure of this approach. Referrals may be considered during the first cycle or after several. “Try Out” logic results in first-visit definitive care in up to 93% of ambulatory encountemz4

In contrast, the specialist regularly deals with situations perceived to be more acute and is inclined to apply the “Rule Out” approach by convention, training, and experience. The patient is considered to be at immediate risk and delay to presage greater morbidity. Diagnosis is sought by ordering all relevant tests to rapidly eliminate all unlikely conditions. Therefore, the “Rule Out” logic format requires more immediate use of resources as is appropriate for hospitalized, referred, or dangerously ill patients. These logic formats are so ingrained that many generalists begin a referral letter to a specialist with a request to “rule out” a list of concerns. The “Try Out” and “Rule Out” logic formats fit different patient presentations and in an ideal system would be selected and applied as appropriate by generalist or specialist. In practice, physicians deMarch

ET AL

Help

Source

Complaint PATIENT

“TRY

OUT”

COMPLAINT

“RULE

OUT”

Figure. Patients access health care when symptoms have exceeded a threshold of tolerance. Once a complaint is articulated, the patient must decide from whom to seek health, selecting a physician also selects a logic format. Generalists tend to use the “Try Out” approach to outpatient problems. The Differential list is used to select most likely and /or immediately threatening possibilities. The “Rule Out” approach is common to the inpatient setting where the differential diagnosis list is used to order all relevant and available tests. In theory, the test results will rule out all but the correct diagnosis. The “Rule Out” method is faster but more costly and invasive. It is less cognitive and increases the risk of false-positive or false-negative test results.

velop routine approaches to patients that predictably exemplify one or the other of these two formats, creating management plans that may, at times, seem illogical to each other and strain the generalistspecialist alliance.

Preparing

to Refer

The riskiest question in general practice is how far to evaluate a patient before referral to a specialist. Too far, and the generalist is accused of mimicking the specialist or wasting time, not far enough, and he/she risks miscategorizing a problem for lack of evidence.25 The generalist is usually assisted by a patient-specific database that has been developed during the primary care continuity relationship.2’6When a decision to refer has been made, the generalist must negotiate insurance coverage, patient denial, missed and delayed appointments, payer regulations, and transportation problems that complicate many referral interactions. Referrals are not made for successfully treated problems, but rather when a chosen or available treatment plan is not working. 27The specialist who is unaware that diagnostic errors can be as common for specialists as generalists, may devalue the genemlist.‘sskills out of a perspective limited by encountering only the generalist’s uncertainties.B As a result, covert negative messagescan interfere with the teamwork needed if 1996

The American

Journal

of Medicine@

Volume

100

339

the patient later seeks supportive advice commonly required for complex problems.25 Most patients who require the services of a specialist will have the same ongoing general health care needs and concerns as unreferred patients. Even when the problem identified by the referral is largely managed by the specialist, the patient or family members often return to the primary care office for interpretations, reassurance, decision making, long-term follow-up, or terminal care. The child with heart disease, for example, returns to the generalist for immunizations, growth and nutrition assessment, school adjustment, and family counseling.2Q Generalists often sense that the specialist is pressured to search for a definitive answer for all problems to gratify the patient and generalist, even when such gratification is elusive, nonexistent, or inconsequential. What the generalist actually seeks is a critical appraisal of current knowledge and technology relative to the patient’s problem. It is this appraisal that expands the generalist’s knowledge and contributes to the development of a holistic, integrated treatment plan specific to the needs of the patient. Focusing Expertise Patients frequently present to a specialist with signs and symptoms of a serious illness, requiring prompt, accurate diagnosis, application of advanced technology, and focused expertise beyond that offered by a generalist. These conditions imply a sense of urgency and inspire a view of disease different from the generalist’s. For example, a cardiologist worries about the impact of heart disease on the cardiovascular system, while the generalist’s view may make the first priority the impact on the patient’s daily activities. This distinction potentiates mismatches regarding the timing of referrals, utilization of resources, and management of patients. The specialist may compensate for any lack of confidence in the generalist’s skill by repeating workups. Inadequate transfer of information from the generalist can further provoke conflict about the referrals indication, contribute to diagnostic delays, and increase repetition.3W2 Concern for outcome after the consultation encourages specialists to seek control of the follow-up period, a situation often less generously interpreted as competition for patient dollars.’ Specialists are justifiably concerned that patients be referred appropriately but promptly and are anxious that the generalist’s limited depth of specialty knowledge not result in a missed, delayed, or incorrect diagnosis. Early and continued bidirectional communication in a relationship characterized by trust and mutual respect allows for prompt referral, appropriate use of technology, patient confidence, follow-up, and optimal patient outcomes. 340

March

1996

The American

Journal

of Medicine@

Volume

Promoting the Patient Professional attitudes have been slow to promote an active role for the patient in referral interactions.6~33 Clear discussion of the patient’s needs, desires, and responsibilities can m aximize referral outcomes. The Patient Self Determination Act, the Americans with Disabilities Act, “do not resuscitate” protocols, living wills, and health care proxies all legitimize active patient control, even when contrary to medical advice. These initiatives mirror a substantial badly of popular literature documenting experiences with illness and healing by health care consumers who reject the presumed helplessness of patientsIndividuals are always at a disadvantage when interacting with organizations because they lack the resources essential to comprehend entrenched inner workings or tmditi~ns.~~~ When ill and dependent, the individual is further disadvantaged, if not disarmed. When referred, the patient must determine how the generalist’s office, the specialist’s office, the hospital, and the insurance carrier reward and interact. While some patients are demanding to be actively informed and involved, others choose to adopt a “learned helplessness” role when they are in a treatment situation.41 Neither the generalist nor the spe cialist can surrender the responsibility to formulate patient care plans, but both are obliged to recognize the patient’s right to negotiate at each level of health care. Insuring Referrals In the fee-for-service era of medicine, economic incentives encouraged the traditional “Rule Out” approach. All chargeable, covered resources were available to diagnose and treat as quickly as possible. Costs were largely ignored and patients were seldom directly responsible for medical expenses. Generalists had few disincentives to refer to specialists and patients were free to request the “Try-out” or “Ruleout” approach according to their perception of illness severity, desire for an “expert’s” opinion, or anxiety. In the managed care environment, insurers, employers, and patients expect highquality care at the lowest possible cost. Provider groups are expected to provide comprehensive services to patient cohorts measured by cost per covered life. Incentives compel the “Try Out” method in which the generalist oversees the process of diagnosis and treatment,, managing re sources that include specialist participation. If the “Try-out” does not proffer immediate gratification, the generalist risks being perceived as a barrier to specialty care. The specialist undertakes a supportive role, available when needed, relying on the generalist to initiate referrals in a timely manner. This shared commitment to achieve the best outcome for each patient requires mutual respect, shared joy in serving patients, and enthusiasm for solving problems. 100

The rationale for managed care comes from studies showing that, even when controlled for patient mix, generalists use fewer resources and charge less than specialists. “” However, managed care introduces new traps and incentives to the doctor/patient relationship by moving generalists beyond coordinating care to controlling resources.46 Most specialists recognize the need for a general care coordinator, but they are concerned that managed care will reduce their autonomy.47

Assuring

Quality

Referrals

In managed care, the referral will continue to form the foundation for interactions among generalist, patient, and specialist. We propose that a successful referral process depends upon achievement of an appro priate balance between the ‘Try Out” method and the “Rule Out” method. Success of the referral process should be built upon the following four quality guidelines.

Engage First, the generalist must establish specific indications for a referral, referencing the patient’s needs, desires, premorbid condition, prognosis, and personal resources.48 Access should not be limited by “gatekeeping” as much as facilitated by expert selection of appropriate services. Patients should be engaged in a proactive discussion about options that can avert an uninformed or misdirected insistence on a nonproductive diagnostic workup.4951 By clearly stating the purpose for a referral, the generalist establishes the patient’s role and the specialist’s responsibility in the health care team. The generalist should articulate specific questions, select the appropriate consultant, and educate the patient about what to expect from the referral. The patient should also be scheduled for another appointment after the referral to assess outcome. The specialist must be sensitive to the referring generalist’s approach to problem solving. Because the generalist’s differential diagnosis is broad and encompassing, the process leading to the referral may have required several spins around the “Try Out” logic format prior to referral. These efforts may have occasioned some delay, but were essential to selecting the appropriate specialist for a condition that may have appeared undifferentiated on presentation. As an example, an adolescent presenting with a minor, but painful, shoulder injury is found to have an asymptomatic systolic heart murmur. The generalist asks the child to return when well in 2 weeks and the murmur is persistent. An EKG is normal, but the generalist is not certain that the character of the murmur is truly innocent. Rather than order an echocardiogram, the generalist discusses his findings with the mother and suggests a second opinion from a cardiMarch

ologist. The adolescent protests that track season is starting and he is not about to be denied his senior year of participation and he does not want to have “a bunch of needles stuck in me.” A discussion about the impact of heart disease found in the asymptomatic stage and that discovered later ensues, granting the generalist an opportunity to answer several questions.

Anticipate A well-defined measurable outcome should be the goal of all referrals. The generalist contributes to definition of the outcome by providing the specialist and the patient with a clear description of the problem, prereferral workup, interventions, contributing, factors, and a review of suspected diagnoses or anticipated pro cedures.V” As the workup progresses, the speci,alist should anticipate patient and generalist conununication, giving specific reference to the questi’ons they raised, clearly describing the value added by the consultation, and preparing to return the patient to the generalist’s care as appropriate. Premeditation ensures the best possible outcome for the patient, strengthens the generalist/patient/specialist referral unit, increases professional satisfaction, and establishes a reassuring sense of continuity to the patient. Returning to our adolescent murmur example, the generalist tells the patient and the mother to expect a complete history will be taken with a focus on birth history, family history, childhood illness, immunization, and activity. The generalist anticipates that an echocardiogram may be ordered unless the cardiologist is certain, after careful examination, that the murmur is innocent. The office staff sets up two appointments: One with the cardiologist and one with the generalist to assure all of the family’s questions were addressed and that consultation met the standards of the patient and the generalist.

Feedback While feedback and communication between patient and physician are usually verbal, letters are the most common mode for interphysician communication. Letters document communication and intentions, while providing structure for quality management. They should describe findings, results, interpretations, diagnosis, treatment plan, follow-up strategies, outcome expectations, and a time line. Letters should be concise but educational, and typed on standard size paper for filing. While specialists have generally been better at communicating by letter than generalists, there are situations that *are complex, ill-defined, evolving, or that require a high degree of generalist/specialist coordination that are better addressed by verbal communication.52 In our example, the generalist dictates a summary letter to the specialist relating as much of the ado1996

The American

Journal

of Medicine@

Volume

1.00

341

lescent’s history as is relevant and a copy of the EKG. The generalist states that a journal article he has read suggests it is more cost effective for the cardiologist to decide when to do the echocardiogram for possibly innocent murmurs. 53 The generalist assures the cardiologist that the adolescent is a high school track star and asymptomatic. After careful evaluation, the specialist returns a letter briefly summarizing the history and relevant physical findings. He/she clearly states the impression of an innocent murmur and delineates the in-office process he/she went through to arrive at that impression. A reference is offered that the generalist might read.

Reassess This is perhaps the evaluation component that has the greatest potential for discovering shortcomings of a referral process and one of several reasons for the generalist to arrange for the patient to attend a postreferral office visit. This visit may reveal a patient’s concern that the problem was not seriously considered, or anger over the perception that the specialist did not use resources wisely, or more often, provide an opportunity to explain the significance of an intervention and the anticipated impact. A direct inquiry of all involved can offer a wealth of evaluative information that will enhance future relationships. The specialist may share concern that referral was unnecessary, or delayed, or that the generalist could have communicated more effectively. The generalist can explore why the specialist did not perform an anticipated procedure or test, or was less than specific in labeling the problem or defining management. Patients should be encouraged to share fears and concerns and to discuss barriers they face in implementing a treatment plan. Systematizing the responsibility of all participants will assure coordinated and completed follow through. Insight developed by these simple inquiries will prevent much dissatisfaction, avoid overlooking problems, and lead to further opportunities for caring. At the postreferral visit, our adolescent is angry because his father has refused to let him run track with a heart murmur and feels that more tests should have been done. The generalist reviews the specialist’s letter with the family and states that with the specialist’s concurrence, he is convinced that the murmur is innocent. He even reads the paragraph in the specialist’s letter that describes the character of an innocent murmur and how useful the exercise in the examination room was to their reassurance. The generalist restates that the adolescent is fit, healthy, and tough as ever, but his cholesterol was in the high-normal range. Exercise should be encouraged, diet altered for the whole family, and a revisit made in 3 months to check the murmur and the cholesterol 342

March

1996

The American

Journal

of Medicine@

Volume

again. The father is scheduled for a physical; and the high school wins the state championship.

Team Building and Caring The referral process is a central mechanism of America’s health care delivery. While more &search is needed to evaluate factors that influence rates, barriers, economics, and outcomes of refer&s, managed care requires specialists and generalists to conceptualize their roles as members of a health care team, while opening up new opportunities for caring, curing, and learning.23,46,51 In the evolving era of .managed care, patients axe asked to accept the generalists’ “Try-out” approach, making the generalist responsible for resource utilization and timing. Developing acceptable models of referral responsibilities will facilitate quality management and optimal patient outcomes. As prloposed here, if generalists, patients, and specialists engage clear indications for referrals, anticipate measurable outcomes, assure adequate feedback, and reassess expectations of all participants, efficient and appropriate use of America’s health care resources is more likely.

ACKNOWLEDGMENT Georgia Rosenthal, preparation.

RN, and Holmes

McGuigan

assisted

in manuscript

REFERENCES 1. Gonzales ML, Rizzo JA. Physician referrals and the medical market place. Med Care. 1991;29:1017-1027. 2. Metcalfe DHH, Sischy D. Patterns of referral from family practice. J Fam Pratt. 1974;1:34-38. 3. Cummins RO, Jarman B, White PM. Do general practitioners have different referral thresholds? BMJ. 1981;282:1037-1040. 4. Wilkin D, Smith A. Explaining variation in general practitioner referrals to hospital. Fam Pratt 1987;4:160-169. 5. Knoitnerus JA, Joosten J, Daams J. Comparing the quality of referrals of general practitioners with high and average referral rates: an independent panel review. Br J Gen Pratt 1990;40:178-181. 6. Grace JF, Armstrong D. Referral to hospital: perceptions of patients, general practitioners and consultants about necessity and suitability of referral. Fam Pratt. 1987;4:17@175. 7. Moore AT, Roland MO. How much variation in referral rates among general practitioners is due to chance? BMJ. 1989;298:500-502, 8. Roland MD, Bartholomew J, Morrell DC, et al. Understancling hospital referral rates: a user’s guide. BMJ. 1990;301:98-102. 9. Reynolds GA, Chitnis JG, Roland MO. General practitioner outpatient referrals: do good doctors refer more patients to hospital? BMJ. 1991;302: 1250-1252. 10. Armstrong D, Britten N, Grace J. Measuring general practitioner referrals: patient, workload and list size effects. J Royal Coil Gen Practitioners. 1988;38:494-497. 11. Shortell SM, Vahovich SG. Patient referral differences among speciaities. Health ServRes. 1975;10:146-161. 12. Rosenthal TC, Holden DM, Woodward W. Primary care obstetrics in rural Western New York: a muiticenter case review. NY State J Med. 1990;90:537-540. 13. Blancquaert IR, Zvagulis I, Gray-Donald K, Pless IB. Referral patterns for children with chronic diseases. Pediatrics. 1992;90:71-74. 14. Gruppen LD, Wolf FM, Voorhees CV, Stross JK. The influence of general and case-related experience on primary care treatment decision making. Arch Intern Med. 1988;148:2657-2663. 100

PRESERVING THE PATIENT REFERRAL/ROSENTHAL 15. Cartland JDK, Yudkowsky BK. Barriers to pediatric referral in managed care systems. Pediatrics. 1992;89:183-192. 16. Coulter A, Noone A, Goldacre M. General practitioners’ referrals to specialist outpatient clinics. BMJ. 1989;299:304-308. 17. Rothert ML, Rovner DR, Elstern AS, et al. Differences in medical referral decisions for obesity among family practitioners, general internists and gynecologists. Med Care. 1984;22:42-45. 18. Armstrong D, Fry J, Armstrong P. Doctors’ perceptions of pressure from patients for referral. BMJ. 1991;302:118&1188. 19. Rosenthal TC, Shrffner JM, Lucas C, DeMaggio M. Factors involved in successful psychotherapy referral in rural primary care. Fam Med. 1991;23:527-530. 20. Laurence L, McLenore T. 1981 Summary: National Ambulatory Medical Care Survey. No. 88. US Department of Health and Human Services publication (PHS) 831250. Hyattsville, MD. National Center for Health Statistics, 1983. 21. Glenn JK, Lawlar FH, Hoer1 MS. Physician referrals in a competitive environment; an estimate of the economic impact of a referral. JAMA. 1987;258:1920-1923. 22. Coulter A, Seagroatt V, McPherson K. Relation between general practices’ outpatient referral rates and rates of elective admission to hospital. BMJ. 1990;301:273-276. 23. Nutting PA, Franks P, Clancy CM. Referral and consultation in primary care: do we understand what we’re doing? J Fam Pratt. 1992;35:21-23. 24. Taylor RB. Categories of care in family medrcine. Fam Med. 1981;13:7-9. 25. Pelligrino ED. The academic viability of family medicine. JAMA. 1978;240:132-135. 26. Hjortdahl P, Borchgrevink CF. Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations. BMJ. 1991;303:1181-1184. 27. Bowling A, Jacobson B, Southgate L, Formby J. General practitioners views on quality specifications for “out patient referrals and care contact.” BMJ. 1991;303:292-294. 28. Rhea JT, Potsasid MS, DeLuca SA. Errors of interpretation as elicited by a quality audii of an emergency radiology facility. Radiology. 1974;132:277-280. 29. Gadding SS, Rosenthal A. The interface between primary care and pediatric cardiology. Med C/in North Am. 1984;31:1367-1388. 30. Weary PE. The cost effectiveness of primary care: a myth or reality? Arch Dermatol. 1981;117:609-610. 31. Doeleman F. lmprovrng communication between general practitioner and specialists. Fam Pratt. 1987;4:176-182. 32. Emmanuel J, Walter N. Referrals from general practice to hospital outpatient departments: a strategy for improvement. BMJ. 1989;299:722-724. 33. Grace JF, Armstrong D. Reasons for referral to hospital: extent of agreement between the perceptions of patients, general practitioners and consultants. Fam Pratt. 1986;3:143-147.

March

ET AL

34. Cousins N. Anatomy of an Illness as Seen by the Patient. New York: Bantam Books; 1983. 35. Frank A. At the WI// of the Body. Boston: Houtonfvlifflen; 1991. 36. Styron W. Darkness Visible: A Memoir of Madness, New York: Random House; 1991. 37. Broyard A. Intoxicated by My Illness. New York: Clarkson Potter; 1992. 38. Stephens GG. Patients on patienthood: new voices from the high tech arena. JAm Board Fam Pratt. 1993;6:183-188. 39. Coleman JS. Power and the Structure of Society. New York: WW Norton; 1974. 40. Hall R. Organizatrons: Structure, Process, and Outcomes. Englewood Cliffs, NJ: Prenhce-Hall, Inc.; 1987. 41. Lumsdon K. Baby boomers grow up: heath active baby boomers Ibegin to flex their muscles as health care consumers. HosprtaJ Heafth Netw. 1993;67:24-34 42. Kravitz RL, Greenfield S, Rogers W, et al. Differences In the mix of patients among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA. 1992;267:1617-1623. 43. Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialtres and systems of care: results from the Medical Outcomes Study. JAMA. 1992;267:1624-1630. 44. Rosenblatt RA. Specialists or generalists: on whom should we base the Amencan health care system? JAMA. 1992;267:1665-1666. 45. Hurley RE, Freund DA, Gage B. Gatekeeping effects on patterns of physician use. J Fam Pratt. 1991;32:167-174, 46. Eisenberg JM. The internist as gatekeeper: preparing the general internist for a new role. Ann Intern Med. 1985;102:537-543. 47. Ellsbury K, Montano D, Krafft K. A survey of the attitudes of physician specialists toward capitation-based health plans with primary care gatekeepers. QRB. 1990;16:294-300. 48. Becker BL. Strategies for managing referral without losing your patients. Fam Pratt Management. 1994;1:109-115. 49. Freis JF, Koop CE, Beadle CE, et al. Reducing health care costs by reducing the need and demand for medical services. NEJM. 1993; 329:321-325. 50. Leigh JP, Fries JF. Health habits: health care use and costs in a sample of retirees. Inquiry. 1992;29:44-54. 51. Vickery DM, Kalmer H, Lowry D, et al. Effect of self care education programs on medical visits. JAMA. 1983;250:2953-2956. 52. Westerman RF, Hull FM, Bezemer PD, Gort F. A study of communication between general pracbtioners and specialists. Br J Gen Pratt. 1990;40:4IW9. 53. Danford DA, Nasir A, Gambiner C. Cost assessment of the evaluation of heart murmurs in children. Pediatrics. 1993;91:365-368. 54. Hunt KE. Relearning primary care: training physicians for marlaged care. Managed Care. 1993;2:19-26.

1996

The American

Journal

of Medicine’

Volume

100

343