A Referral is the Building Block of your Health Care Network.

By: Amish Shah, MD, MPH, ReferWell

In today’s environment, health care has become increasingly specialized. Primary care physicians (PCPs), once careful to refer patients out in the “gatekeeper” HMO model, have now left these habits behind and come to see themselves as coordinators of care among the patient’s multiple specialists. Part of this is explained by the advancement and complexity of medical science, the desire to improve patient satisfaction, and also avoid medical malpractice. According to a recent article, the referral rate has more than doubled in the last decade, with approximately 10% of outpatient visits leading to a referral.

Given this new paradigm of PCP-coordinated care, how can an Accountable Care Organization or insurance provider hope to maintain satisfaction for their covered individuals while reigning in out-of-network charges? The answer begins with the understanding that the referral is the building block of the network. Without a focus on the targeted referral, a network is simply a group of loose affiliations.

Patients themselves do not often understand who they should see for any particular problem. Most know to call 911 for an emergency, which would lead to an Emergency Department visit. Some would consider going to an Urgent Care center for more minor concerns. If they have an existing provider relationship, some might call their PCP or a specialist directly, especially for chronic problems. A few might call their insurance company or network for guidance. While initiatives targeting the patient to reign in out-of-network usage are possible, they also risk the perception of being obtrusive.

Empty pockets
Patients themselves do not often understand who they should see

However, no matter how the patient makes initial contact with the health care system, what happens next is much more amenable to influence without presenting a burden. Physicians and their staff in the medical system have a much greater ability to steer patients toward a particular network, mostly because they want their patients to get the best possible care. And if that network features close coordination, the referrals keep all downstream care within it. Furthermore, the closer the coordination of care and the greater the ability to keep the patients in-network, the higher the perception of quality!

How does one approach the problem of creating a closer, more efficient network? The first step, as highlighted by many recent writings in health care journals, is to develop an understanding of the referral patterns within a group. Are physicians continuing to send referrals away for reasons such as old habit or poor knowledge of in-network providers? Are they unfamiliar with certain providers and the care that the patient might receive? Are PCPs confident that they can provide their patients resources that will deliver effective, excellent care with convenience? Finally, is there a convenient way to send the referrals and coordinate information?

Technology has the potential to build a strong, close network out of loose affiliations. ReferWell.com has developed a web-based platform to help make referrals and share information among providers fast, easy, and convenient. We keep patients traveling within your network to prevent leakage. Referrals within the network can also be steered toward available or less costly providers, similar to strategies used by early successful ACOs. We give patients confirmed appointments and help avoid test duplication, freeing them from frustration and hassle. We help implement our approach in providers’ offices to make their workflow smoother. Finally, we provide reporting and metrics to help you understand how and why patients are moving through the system, so you can see the financial results and target corrective measures.

The referral is the building block of your provider network. Let us help you make your foundations stronger and more effective.

Sources:

  1. Song, Z et al. “Patient Referrals: A Linchpin for Increasing the Value of Care” JAMA 2014, Aug 13; 312(6): 597-8.
  2. Barnett, ML et al. “Trends in physician referrals in the United States, 1999-2009.” Arch Int Med 2012; 172(2):163-170
  3. Mehrotra A et al. “Dropping the baton: specialty referrals in the United States.” Milbank Q. 2011: 89(1):39-68