Receiving and providing referrals within healthcare can be challenging. There are many criteria: Are the potential providers in-network? Are they seeing new patients? Do they fit the patient’s particular preferences on location, language, etc.? If surgery is required, do they admit to a hospital that is in-network for both the specialist and the patient’s PCP? Beyond these typical considerations, there are several more that are rarely contemplated by referring physicians due to a lack of information and awareness. These include provider quality and outcomes, data-sharing capabilities, and guiding patients already enrolled in value-based care programs into optimized care pathways.
Patients will go to a specific referral from their provider about 70% of the time, so it’s critical that patients are referred to the right provider at the right time for the right care. However, in the current state, it is unlikely that physicians and their staff will take into account all of the above considerations. One indication of this gap is the statistics around out-of-network and out-of-care network referrals, which drive up the cost of care for patients.
New technologies are emerging to help physicians make better-aligned referrals for their patients’ needs. These technologies are being tied into EHRs to make suggestions based on insurance information to ensure that the provider is in-network. However, these products will only be as reliable as the information that is readily available, and therefore, insurers will need to have a clear understanding of which members are enrolled in which value-based programs. Having up-to-date directories that show which providers participate in these same value-based programs will help to close the gap around referrals and value-based care. This will help physicians to make smarter choices on behalf of their patients.
As more information becomes available, we can start to see these technologies assist the referral process even more. As pricing becomes more transparent and quality becomes more visible, it is easy to imagine a referral system that takes into consideration not only whether a provider is in-network for the insurance, but if they are part of the same ACO as the referring provider as well. This system could also share data across all members of the patient care team, recommend value-based programs that focus on quality over quantity, and rate well based on both price and quality. Patients do not have easy access to anything other than if the provider is part of their plan, and rarely do they have the knowledge to understand the meaning behind the other components. However, given the right data points, physicians could arrive at better decisions for their patients.
As technology races to meet the needs of physicians in the field, it is key that the referral process takes the right information into consideration. Otherwise, excess costs and disjointed care will be perpetuated further. Ensuring that providers get the data they need to choose the best physicians referrals for their patients is critical, not just for the goal of improving quality in the healthcare system, but for the patient’s safety and satisfaction. By taking all data into consideration, the patient’s needs can be met in a real and meaningful way.
Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs
Solving the ACO’s Out-of-Network Utilization Problem
Strategies for Generating Savings in an ACO: Out of Network Utilization