Referral Management: Why It’s More Critical than Ever

Guest post by Adam Sharp, MD, CMO par8o.

Adam Sharp, MD
Adam Sharp, MD

There is an industry-wide surge in providers, payers and post-acute care providers whose needs for transitions-in-care are unmet by their current healthcare IT capabilities. As such, 2016 will likely be the year that referral management comes to the forefront for all stakeholders in the healthcare system.

The moment of referral is an opportune time to engage with patients: with the increase in high-deductible plans and out-of-pocket expenses, patients are extremely motivated to seek care from high-quality, cost-effective, in-network providers. Providing patients with the resources they need, while enabling providers to align their efforts, is a mission-critical need in healthcare today.

There are a few key factors driving improvements in referral management for providers, payers, and post-acute care providers alike:

For providers

With the move to fee-for-value reimbursement, we are seeing a rise in the number of physicians moving to independent physician associations, ACOs, and clinically integrated networks.  This is happening for two reasons: first, to negotiate more effectively with payers and second, to equip themselves to take on risk in the future.  In order to take on risk effectively, healthcare organizations will need to ensure that patients stay within their systems.  In addition, these groups of physicians often have multiple EMRs and are looking for solutions to expand them.  Therefore, we have seen an increase in all kinds of provider groups looking for intelligent decision support that guide referrals in a systematic and strategic fashion.

For payers

With the increase in high deductible, narrow network plans, there is a greater need to direct patients to high-quality, low-cost providers.  Payers, in partnership with providers, are looking for the ability to navigate patients in this way. Given the cost of specialist visits, payers are also particularly interested in making sure patients get to the most appropriate specialist to receive the care they need.

For example, Carefirst BCBS has pioneered a program, through their PCMH plan, to provide information on specialist costs and quality to inform referrals.  They see this as a way to improve quality while, over time, bending the cost curve.  This could be the beginning of a broader trend among payers, to acknowledge the importance of referrals and encourage the use of tools designed to implement insightful decision support and a standardized process around transitions-of-care.

For post-acute care providers

As providers have consolidated, so has the post-acute care space.  Readmission penalties and bundled payments have further put pressure on post-acute care to ensure a seamless transition from acute care to – and within – different post-acute services.

As a result of both of these trends, post-acute care companies, similar to clinically integrated networks, are looking to improve cost and quality of care across multiple settings and EMR systems.  There are no easy solutions, particularly for this segment.  Referrals are often done in a highly manual way, with information patched together using Sharepoint or a tool not designed for this purpose.  Dedicated referral management technologies will ensure effective access to post-acute resources and enable post-acute networks to better coordinate care while working effectively with partners to embracing bundled payment models and shared risk.

Standardized referral processes with decision support commensurate to specific patients’ needs are essential to succeeding in a fee-for-value world.  It’s a world in which most providers cannot complete referrals across different EMRs, and don’t have the necessary data intelligence to guide the referral decision; not a world fit to best serve providers, payers, or patients. Ultimately, it is the patient that benefits from the right care where and when they need it.

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