Swedlow A, Johnson G, Smithline N, Milstein A
National Medical Audit unit, William Mercer, Inc., San Francisco, CA.
N Engl J Med. 1992 Nov 19;327(21):1502-6. doi: 10.1056/NEJM199211193272107.
There is widespread concern that ownership by physicians of testing or treatment facilities to which they refer patients leads to overuse of such facilities. We determined the patterns of use of three services--physical therapy, psychiatric evaluation, and magnetic resonance imaging (MRI)--among physicians treating patients whose care was covered under workers' compensation. We then compared the rates of use among physicians who referred patients to facilities of which they were owners (self-referral group) with the rates among physicians who referred patients to independent facilities (independent-referral group).
We used a large data base to analyze claims under workers' compensation in California from October 1, 1990, through June 30, 1991, to determine the frequency and cost of these three selected services and determined whether the referring physicians were practicing self-referral or independent referral. We evaluated the cost per case for all three services, measured the frequency with which physical therapy was initiated, and evaluated the medical appropriateness of MRI.
We found that physical therapy was initiated 2.3 times more often by the physicians in the self-referral group (68 percent) than by those in the independent-referral group (30 percent; P < 0.01). The mean cost per case for physical therapy was significantly lower in the self-referral group ($404 +/- 102) than in the independent-referral group ($440 +/- 167; P < 0.01). The mean cost of psychiatric evaluation services was significantly higher in the self-referral group than in the independent-referral group (psychometric testing, $1,165 +/- 728 vs. $870 +/- 482; P < 0.01, psychiatric evaluation reports, $2,056 +/- 1,063 vs. $1,680 +/- 578; P < 0.01). The total cost per case of psychiatric evaluation services was 26.3 percent higher in the self-referral group ($3,222 +/- 1,451) than in the independent-referral group ($2,550 +/- 742; P < 0.01). Of all the MRI scans requested by the self-referring physicians, 38 percent were found to be medically inappropriate, as compared with 28 percent of those requested by physicians in the independent-referral group (P < 0.05). There was no significant difference in the cost per case between the two groups.
This study demonstrates that self-referral increases the cost of medical care covered by workers' compensation for each of the three types of service studied.
人们普遍担心，医生拥有他们将患者转诊至的检测或治疗设施会导致这些设施的过度使用。我们确定了在处理工伤赔偿覆盖患者的医生中，三种服务——物理治疗、精神科评估和磁共振成像（MRI）——的使用模式。然后，我们比较了将患者转诊至其拥有的设施的医生（自我转诊组）与将患者转诊至独立设施的医生（独立转诊组）的使用率。
我们使用一个大型数据库来分析1990年10月1日至1991年6月30日加利福尼亚州的工伤赔偿申请，以确定这三种选定服务的频率和成本，并确定转诊医生是进行自我转诊还是独立转诊。我们评估了所有三种服务的每例成本，测量了开始物理治疗的频率，并评估了MRI的医学适宜性。
我们发现，自我转诊组的医生开始物理治疗的频率（68%）是独立转诊组医生（30%；P<0.01）的2.3倍。自我转诊组物理治疗的每例平均成本（404美元±102美元）显著低于独立转诊组（440美元±167美元；P<0.01）。自我转诊组精神科评估服务的平均成本显著高于独立转诊组（心理测试，1165美元±728美元对870美元±482美元；P<0.01，精神科评估报告，2056美元±1063美元对1680美元±578美元；P<0.01）。自我转诊组精神科评估服务的每例总成本（3222美元±1451美元）比独立转诊组（2550美元±742美元；P<0.01）高26.3%。在自我转诊医生要求的所有MRI扫描中，38%被发现医学上不合适，而独立转诊组医生要求的MRI扫描中这一比例为28%（P<0.05）。两组之间的每例成本没有显著差异。
这项研究表明，自我转诊增加了工伤赔偿所涵盖的这三种服务中每种服务的医疗费用。
