Over half of the patients from this study (n = 117 (57%)) had some, or a lot of, input into the choice of a healthcare provider at the point of referral. The other 43% of the patients had little or no input, meaning that the GP chose a healthcare provider for them. Differences were visible in how patient choice is incorporated during the consultation. The influence of the patient’s health insurer or insurance policy in choosing a healthcare provider at the point of referral is minimal, insofar as this decision is taken within the GP consultation. In only 14% of the consultations topics regarding the health insurer or insurance policy of the patient were discussed.
Comparison with existing literature
In 2015/2016, more patients seem to have some, or a lot of, input into the decision to choose a healthcare provider compared to 2007/2008 . However, we still found that in most consultations the GP chose the hospital or specialist on behalf of the patient. Existing literature has already pointed out that patients usually visit the healthcare provider that is recommended by their GP [9, 13,14,15, 19, 21, 28, 29]. GPs themselves also experience that the patients’ demand for choice during their referral is limited and usually expressed in a demand to be sent to the nearest hospital .
Patients do not seem to act as actively as presumed by policymakers, which firstly might be due to the fact that the gatekeeping function performed by primary care has a strong foundation in the Netherlands . This means that the GP influences the referrals to specialist care, which might result in patients feeling as if they do not have the autonomy to make their own decisions. However, it might also be that the quality and the duration of the relationship between the GP and the patient influences the form decision-making takes. In a long-term continuous relationship with the patient GPs often are familiar with the preferences of the patient and act on them . Secondly, the duration of consultations in the Netherlands is only ten minutes, which might be too short to discuss multiple referral options. As a result, GPs might opt for the obvious option. Thirdly, patients might experience a lack of insight into the quality of healthcare providers and are, therefore, reluctant to decide on a healthcare provider themselves . Lastly, patients may not feel that the choice of a provider is as important as policymakers do .
Although GPs are divided about if discussing costs issues with patients belongs to the profession’s job responsibilities, all providers are obliged to provide patients with the information that is relevant for them to be able to make an informed choice [33, 34]. Besides, GPs are expected to involve their patients into decisions about their care and to aid to empowering them to do so [20, 35, 36]. However, it is demonstrated in this study that most GPs do not involve patients in the decision-making process regarding a referral destination during consultation. Studies indicate that, because of a lack of time, the GP cannot reveal all information about the different possibilities when advising patients about their choice [6, 30]. GPs refer patients to a particular hospital, for instance because their care history is known there or their diagnosis is unknown at the moment of referral because of which they are unable to refer to a hospital that specializes in their condition . This was also demonstrated in the results of this study. In most of the consultations other referral options were not discussed and only practical information about the healthcare provider seems to have been provided to patients. The reason for referring to a specific healthcare provider was rarely explained to the patient.
Lastly, our results indicate that topics regarding the health insurer/insurance policy of the patient are barely (N = 16 (14%)) taken into account when choosing a healthcare provider. This aligns with previous research that found that of 219 people, only 22 (10%) said that their health insurer played a role in their decision to choose a hospital or specialist . A possible explanation for this might be that it is complicated and time-consuming for GPs to discuss topics regarding the health insurance of a patient because each patient has a different insurer and is insured differently. Policymakers and health insurers might expect GPs to inform patients about the consequences that their referral decisions can have. However, it could also be that GPs and patients do not see the point of discussing matters about costs instead of medical content during their consultation time. Health insurers themselves should inform GPs and patients of the importance of discussing matters around the health insurance policy of the patient. They should also provide patients with information about healthcare providers to enable them to make choices. A last reason that the health insurance of the patient is seldom taken into account during referral might be that, in the Netherlands, the consequences, especially financial ones of selective contracting are barely visible. Nowadays, selective contracting rarely occurs and patients are nonetheless compensated for most costs incurred at non-contracted providers, but selective contracting is expected to gain more importance over the next few years . Therefore, it will become more important for patients, and for GPs if they want to support patient decision making, to take patients’ health insurance into consideration when choosing a healthcare provider.
Strengths, limitations and further research
Few studies have analysed actual GP-patient consultations in order to study the patients’ role in the referral decision, and GPs’ support for patients who are actively choosing a provider. Observations are a more objective source of information than self-reporting by patients or GPs, which could be biased. In addition to the first study from 2007 to 2008 , this study has also observed the role that the health insurer or insurance policy of the patient plays in making a decision on a healthcare provider at the point of referral. A final strength of this study is that the GPs participating were unaware of the fact that the observations focused on referral decisions. Therefore, the Hawthorne effect, a possible limitation of observational research, is minimal and our results mirror the actual daily situation in general practice.
A limitation of this study is that observations do not give insight into the underlying motives for behaviour and attitudes. For example, what is the underlying reason for a GP to send someone to a specific hospital? It is also unclear if patients complied with their GP’s advice or went anywhere else. Neither was any account taken of the behaviour of the same patients in previous consultations or with the possible existing doctor-patient relationship that could influence the input of a patient about the choice of a healthcare provider. In addition, we did not look at whether patients or GPs find it relevant to discuss topics regarding the health insurance of the patient. Another limitation is that 20 of the 28 GPs were from the east of the Netherlands, because of which our results might not be generalizable to an entire population. Nevertheless, our sample matches the population of Dutch GPs with regard to age and gender . Yet another limitation is that the lowest Kappa score that we had (0.45), was moderate . However, the agreement score for this item was better (mean 64.9%). Nevertheless, our results should be considered with some caution. Lastly, there were differences in how many patients were observed per GP, ranging from one patient to 29 patients. However, conducting multilevel analysis was unnecessary, because the observations per question of the observation protocol for each GP were distributed, meaning that, for instance, a specific GP did not always ask patients for their preferences, but sometimes did while, at other times, did not.
Future research could focus on the importance of costs in making a decision to choose a healthcare provider during a GP consultation. Thus, investigating whether the idea of the importance of taking the health insurer or insurance policy into account when choosing a particular healthcare provider is something which is gaining support from both the GP and the patient. Further research could also focus on the importance of shared decision-making when choosing a healthcare provider during GP consultations. This means investigating what GPs and patients think of the idea that GPs are expected to encourage patients to make an active choice about a healthcare provider. Furthermore, it is interesting to study if an active choice makes a difference for health outcomes.