Background: Appropriate utilization of primary physician and specially care has stimulated substantial debate, but the portion of discussion focused on policies that restrict or discourage direct access to specialist. We examined the self-referral incidence rate and the association of health care delivery system structure with utilization of primary physician and specialist.

Materials and Methods: Office visit for patients in private sector and outpatients in public clinic care, stratified by insurance status (Rural Health Insurance, Imam Khomeini Welfare Committee, private insured patients and non insured patients or self-pay patients). 1306 subjects were randomly selected for the study purpose. 39.9% were covered by Imam Khomeini Welfare Committee, 14% Rural Health Insurance, while 46.1% were open for direct referral to specially services.

Results: In Imam Khomeini Welfare Committee closed loop referral system, 6.8% of patients were direct self-referral. In rural health insurance 29.7% of patients were direct self-referral, while in open referral system 75.5% of the patients were direct self-referral to specialist. Significant association was detected between the structure of health care delivery system and patient self-referral of specially cares. The incidence rate of self-referral in public sector was 60.5 and in private sector was 36.4%. Significant association was detected between public and private sector self-referral (P<0.001). Patients’ reasons for skipping the general practitioner were high specialist competency as those problems were specific for the specialist waste of time, friends’ recommendation and weakness information about referral system.

Conclusion: The results suggest greater utilization of specialist in open referral system. Closed loop referral system like Imam Khomeini Welfare Committee may reduce some of these disparities.