J Manipulative Physiol Ther 2005 (Mar); 28 (3): 170–174 ~ FULL TEXT
Coulter ID, Singh BB, Riley D, Der-Martirosian C
UCLA School of Dentistry,
OBJECTIVE: To determine the interreferral patterns among physicians and complementary and alternative medicine (CAM) providers in an independent practice association integrated medical system.
METHOD: Data from a 1-year period were collected on referral patterns, diagnosis, number of visits, cost, and qualitative aspects of patient care. The independent practice association provided care for approximately 12,000 patients.
RESULTS: In the selected integrative network, there are those primary care physicians (PCPs) who refer and those who do not. Among those PCPs that refer to CAM, a preference is shown for a limited number of providers to whom they refer. Although doctors of chiropractic get more referrals, they are also more concentrated among selected providers than are doctors of oriental medicine.
DISCUSSION: The data resemble a good news/bad news scenario. For the good news, in this network, of the 42 PCP providers, only 3 are not linked through referrals to at least one CAM provider in the period studied. But the bad news, however, is that for most of the PCPs, the number of referrals is quite low. Any CAM provider relying solely on the referrals to generate a patient flow would not do very well in this network. This finding might reflect either the nature of the patient population, one which does not necessitate referral, or may reflect reluctance or inexperience on the part of the PCPs with the type of CAM therapy offered by DOMs or DCs.
Looked at in the context of the broader question about the future of integrated systems, although the number of integrated delivery systems is expanding rapidly, they are encountering difficulties.  This is partly a result of the complexities involved. As Shortell et al  noted, 3 levels of integration have to be achieved: administrative integration, practitioner-system integration, clinical integration. However, there is a dearth of information about how the integration of CAM and conventional systems is progressing. In the case of chiropractic, no studies have been done on the new chiropractic role in emerging CAM clinics.  He reports on one survey intended to benchmark the barriers to cooperation of practitioners such as naturopathy, herbology, homeopathy, acupuncture, massage, mind-body methods, and manual and manipulative therapies in 25 clinics and 5 additional nonbenchmark CAM clinics. [18, 19] The results show that the degree of integration varied considerably. Somewhat more sobering is that few integrative clinics are economically sound. 
CONCLUSION: This study shows the interreferral patterns among the PCP and CAM providers working within an integrated medical system. One effect of being in the network for doctors of chiropractic and doctors of oriental medicine might be the possible interreferrals between each other.