this also entails giving difficult cases sufficient resources and conserving resources in cases where their use would be suboptimal furthermore changes in payment systems could have longterm consequences for technology use medical practices and costs over time mcclellan they have however not been effective in avoiding unnecessary referrals and offering definitive care between and the number of nondiagnostic 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 gaal et al