This also entails giving difficult cases sufficient resources and conserving resources in cases where their use would be sub-optimal. Furthermore, changes in payment systems could have long-term consequences for technology use, medical practices and costs over time (McClellan, 2011). They have, however, not been effective in avoiding unnecessary referrals and offering definitive care. Between 1990 and 2008, the number of non-diagnostic referrals to outpatient specialist care increased by more than four times, while the number of patients referred to inpatient care per physician increased by almost 80% (Gaal et al.,