Access to Specialists:

The large majority of Americans -- 83 percent -- expressed confidence that their physician would refer them to a specialist when the situation called for it, according to findings from the Household Survey conducted by the Center for Studying Health System Change. But a meaningful share, 16 percent, worried that their doctor might not make a referral when one was genuinely needed. This concern was not evenly distributed: the proportion of worried patients ranged from a low of 11 percent in Lansing, Michigan, to a high of 22 percent in Miami.

The Referral Process Under Managed Care

A key element of the patient-physician relationship was trust that doctors would act in their patients' best interest, including arranging specialty care when medically warranted. By the late 1990s, changes in the health care market -- particularly the growth of managed care -- had made the role of primary care physicians in specialty referrals more formalized and, in some cases, more restrictive.

Various utilization management procedures and financial incentives had been put in place to encourage primary care physicians to reduce the use of unnecessary or inappropriate services, including some specialty referrals. While these mechanisms were designed to curb waste, both patients and some physicians expressed concern that the incentives might restrict access to specialists even when their services would be beneficial.

What Primary Care Physicians Reported

According to the Center's Physician Survey, most primary care physicians (82 percent) reported that they were always or almost always able to obtain referrals for their patients to high-quality specialists when medically necessary. However, nearly one in five (18 percent) said they could not consistently secure such referrals, even when medical necessity was clear.

The difficulty of obtaining specialist referrals varied considerably across communities. Primary care physicians in Miami (31 percent) and Newark (31 percent) were substantially more likely to report difficulty. Those in Indianapolis (6 percent) and Boston (12 percent) were the least likely to experience such problems.

Patient and Physician Perspectives Compared

The community-level data revealed some alignment between patient worries and physician-reported difficulties. In communities where more patients expressed concern about referrals, physicians also tended to report greater difficulty arranging specialist access. The full breakdown by community, showing the share of patients concerned about referrals and the share of primary care physicians reporting difficulty, respectively: Boston (12 percent, significantly different, 12 percent, significantly different); Cleveland (15 percent, 14 percent, significantly different); Greenville, S.C. (16 percent, 14 percent, significantly different); Indianapolis (13 percent, significantly different, 6 percent, significantly different); Lansing (11 percent, significantly different, 19 percent); Little Rock (17 percent, 17 percent); Miami (22 percent, significantly different, 31 percent, significantly different); Newark (14 percent, 31 percent, significantly different); Orange County (20 percent, significantly different, 26 percent); Phoenix (18 percent, 23 percent); Seattle (13 percent, significantly different, 15 percent, significantly different); Syracuse (12 percent, significantly different, 13 percent, significantly different).

For metropolitan areas with populations over 200,000, the averages were 16 percent of patients concerned and 20 percent of physicians reporting difficulty. Nationally, both figures stood at 16 percent and 18 percent, respectively.

What These Findings Suggested

The geographic variation in both patient concern and physician-reported difficulty pointed to real differences in how health care markets functioned across communities. In some areas, the combination of managed care structures, provider availability, and insurance plan design created genuine barriers to specialty access. In others, these factors aligned more favorably, and both patients and physicians reported fewer problems.

The fact that Miami and Newark stood out -- with nearly a third of primary care physicians unable to consistently arrange specialist referrals -- suggested that certain market conditions, such as high uninsurance rates, large Medicaid populations, or concentrated plan control over referral networks, could seriously impede access to specialty care. By contrast, Indianapolis, where only 6 percent of primary care physicians reported difficulty, appeared to have market conditions more conducive to referral access.

Sources and Further Reading

This Data Bulletin draws on findings from both the Household Survey and the Physician Survey, conducted as part of the Community Tracking Study by the Center for Studying Health System Change. The surveys covered 12 randomly selected metropolitan areas and a nationally representative sample. Statistical significance is noted where site values differ from the mean for metropolitan areas with populations over 200,000.