Electronic Health Reporter

Guest post by Chris Lukasiak, senior vice president, MyHealthDirect.

In the U.S., more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Referrals are the link that make this connection between primary and specialty care. From 1999 through 2009 alone, the absolute number of visits resulting in a physician referral increased 159 percent nationally, from 41 million to 105 million. This volume and the frequency of specialty referrals has steadily increased over the years and will only continue. Yet despite this rise in frequency, the referral process itself has been a great frustration for years.

Specialty referrals are a complicated business. There are many moving parts and players that all have a crucial role to play within the process. By breaking it down and looking at exactly what a referral is, who is involved, and the challenges they face, we can then look to fix what is broken. What needs to be improved? And could there be a digital solution?

Let’s start from the very beginning by looking at the stakeholders and their unique interests and concerns.

Patient – The patient experiences a health concern and needs care to get it resolved. The primary physician doesn’t provide the full solution and refers them to a specialist with more expertise about the patient’s condition. This is where the referral occurs. Currently, the extent of the referral is the physician handing a phone number to the patient to call and schedule the appointment. It’s up to the patient to contact the specialist and follow through with the next step, which explains why 20 percent of patients never even schedule the referral appointment.

Provider –There is more than one provider involved in the referral process. First is the referring (or sending) provider and then the target (or receiving) provider. The referring physician is the provider recommending (referring) them to a specialist. The target provider is the specialist that has been recommended. For a health system or physician group, there are obvious financial and quality of care benefits associated when a patient is sent to a trusted provider within network. When patients don’t go to their referral appointment, the health system or physician group loses in several ways. First of all, they have lost control over providing comprehensive care to the patient. If a patient gets readmitted to a hospital because of their negligence to follow through on a referral appointment, the health system gets penalized for the readmission. The penalty could result in CMS withholding up to 3 percent of the funding provided to the health system. The system also suffers in terms of the perception of their quality of care. If a patient is not secured with a provider within network, they may go to a competing system.

Plan – Health plans have several important considerations when a referral happens with a vested interest on three fronts to ensure the patient goes to the target provider:

1) The health plan benefits if the patient goes to a target provider within their network. Not only will patients be directed to providers that best meet their needs, but the plan also benefits when patients are referred to the providers in their Smart Network. These providers are trusted for superior care for the patient and reduced costs for the plan.
2) When a plan member doesn’t get the care they need to maintain good health, their likelihood of having major adverse events rises dramatically. This means they will end up in the ER or needing other expensive care, which represents big costs for the health plan.
3) The current approach to referrals often results in long lead times, which makes for a poor patient experience and can increase costs.

When we truly examine each player involved in the specialty referral process, the takeaway is obvious – even when it works, the process is inefficient, if not altogether broken. So what would it take to straighten things out? To improve patient access in its current form, we need to address the needs of each stakeholder – but how?

We can digitally alleviate the issues and inefficiencies that currently bog down our healthcare system in the referrals arena by leveraging digital systems to improve the process for each member involved.

Patient – Allowing patients to self-schedule online at their own convenience means they can book appointments after business hours and stay engaged in their care. With quick calendar synchronization to mobile devices, digital reminders help boost the likelihood that they actually attend the appointment as well.

Provider – Delivering an online interface for the referring provider to book appointments into target providers’ calendars is a huge efficiency gain. Before leaving their initial visit, the patient already knows who their next appointment is with and when. The appointment is scheduled in real time and integrated directly into the target provider’s calendar. Through the platform, providers have the ability to send notes to the receiving specialist and track attendance and outcome of the visit.

Plan – In addition to helping providers and patients solve the issues mentioned above, a plan must provide comprehensive service across the continuum of care. Each referring provider is able to search across system providers and quickly schedule the patient with the right provider, with the earliest availability. Not only does this increase efficiency, but it also adds the tremendous benefit of eliminating outward migration. As plans focus on trust and loyalty of their brand, a solution with a consistent look and feel offers a superior patient experience. Lastly, plans with the ability to monitor referral behavior at the network level can optimize and drive real behavioral change.

Specialty referrals are on the rise, and will continue to increase in the coming years – there’s no doubt about it. We must look to technology to update old systems and improve processes. By peeling back the layers and looking at the issues facing each stakeholder, we can pinpoint specific needs and digitally connect the missing links to create a lasting solution.