The Data Show Providers Lack The Necessary Information When Making Referrals

Our recent blog post discussed how the vast majority of consumers rely on their doctor for advice and guidance on care decisions.  We concluded the post by saying, “the bottom line is that to save costs on healthcare treatments, we need to provide better decision making tools to the doctors, not the consumers.”  A new study on physician referrals supports this assertion, concluding that referring physicians lack data on specialist providers and scheduling options when making a referral, which impedes care coordination.  Let’s unpack the results of the study…

According to the study, most providers, 77% of them, recognize the importance of keeping patients in-network by referring their patients to in-network specialists, yet four out of five providers refer out of network.  Referring out of network isn’t inherently bad.  Referring to an out of network doctor could provide better outcomes and/or lower costs for the patient.  However, the data show that providers are referring out of network not because it is a better choice for the patient, but rather because providers lack the appropriate information to make an in-network referral.  Among providers who refer out of network, 45% say that it is difficult to determine which specialists are in-network.

Marc Lachs, VP at Optum, says that, “one of the core issues is the provider directory—just knowing what doctors are in a network, what type of provider they are, where they are located, what insurance they accept. That is something we see individual practices and large health systems really struggle with." By providing providers with the tools and information to identify in-network specialists, a payer or provider network could dramatically improve care coordination and retention, while boosting their bottom line.  The providers surveyed believe that one-third of out-of-network referrals would be avoidable with more information (we believe that number to be closer to 80%).

The referral management tools on the market today have features beyond just identifying in-network providers to help payer and provider networks improve care coordination.

• Identifying the right specialist: Three-fourths of providers say that they usually refer patients to the same provider within a given specialty.  This means that most provides are not taking into consideration factors that are important to the patient such as network, expertise, location, insurance, and availability.  With the right data, referring providers can identify the right in-network specialist.  Getting the patient to right specialist will improve patient outcomes and satisfaction rates, which will help CAHPS, HEDIS, and STAR measures.
• Point of care scheduling: Two-thirds of providers believe the it is very important to schedule the patient’s appointment with the specialist before the patient leaves the office.  Currently, half of all referrals do not result in a visit.  ReferWell has found that scheduling the patient appointment at the point-of-care increases compliance rate by over 60%, resulting in cost savings and a reduction in ED visits.  Despite the fact that both the data and providers support point-of-care scheduling, only 4 in 10 patients leave their providers office with a referral appointment scheduled.
• Interoperability: Of the 40% of providers that schedule an appointment on behalf of their patient, 44% do so within a shared EMR.  Hospitals, on average, have 16 different EMRs, meaning providers are only viewing a narrow slice of the network when making a referral.  Moreover, EMRs enable providers to send clinical data, but do not help providers identify who to send the clinical data to – there is still a specialist identification problem.  Referral tools not only allow providers to identify the right specialist, but they also allow providers to share clinical data across disparate EMRs.  For the payer or provider network, a referral management tool can help to quickly and easily create a truly integrated care network.

There are tools on the market that can help providers identify the right specialist and schedule the referral appointment on behalf of the patient at the point-of-care.  These same tools can also provide actionable insights to the payer and provider networks to help shape provider behavior to minimize out-of-network referrals.  The concluding point from our last blog posts still stands: “the bottom line is that to save costs on healthcare treatments, we need to provide better decision making tools to the doctors.”