It’s a usual day, several in-patients are under your care, many scheduled patients are already seated in the waiting area and the ambulance has brought in an emergency case. On top of this, a heap of paperwork promise to cut your lunchtime in half. In between, scheduled patients come in and some of them need to be referred out. Patient referrals can be the time-consuming and tedious process, but it is also very important.
Theoretically, referral process is simple – if the initial diagnosis concludes that the patient needs special care or medical guidance then the patient’s primary provider will suggest few providers or will schedule an appointment for the patient with a specialist. The patient fulfills their end of the bargain by going to the specialist and getting treated.
In practice though, the provider will suggest a specialist because that is the only specialist the provider knows, checking for availability of the specialist and actually getting an appointment is easier said than done and even with all the effort the patient may end up going to another specialist, if at all.
There are more at stake here than just a few missed appointment. Statistics show that a number of medical referrals are on the rise in the US and with referrals gaining importance, not only is it critical for the patients, but also to the practice. Following are a few reasons why referrals are important:
Care Outcome: In an industry under transformation from fee-based to performance-based, the medical outcome and patient experience will continue to become more important, a trend most visible in an Accountable Care Organizations (ACOs) setup. ACOs are responsible for the health of a population they serve and shares cost of care with Medicare, if the cost of care exceeds the preset limit and/or the quality is not up to the standard then it could affect ACO reimbursement. Most of the time the referring provider has no clues to what is the cost of the specialist he/she is referring the patient to or of the quality for that matter.
Revenue Management: Referring a patient could be a risky gamble from a revenue management perspective. There may seem as though that the only revenue inflow from a referral is for the specialist. A primary provider who refers patients out of his practice to a specialist he/she knows may even result in once again referring the patients to other healthcare systems, even a rival hospital system. Perhaps the provider is sending the patients to the right specialist but unknown to him/her the patients have been going to another specialist and the provider and their practice is affecting the future revenue without even knowing it.
To Refer Or Not To Refer: A patient is referred to a specialist when a provider establishes a reason for specialist care and the complexity of the patient’s condition is beyond the range of the primary provider and so requires an expert. Here lies the problem, as straightforward as it may sound, the parameters that would necessitate the initiation of referrals are vague at best. Wrong decisions on referral can be a problem.
How big a problem? Anywhere between the unwanted cost at the least or even legal entanglement. Wrong referral leads to uncalled expense, if the primary provider refers to a specialist with different capabilities that are not quite what the patients require or is not referred at all The patient’s conditions could worsen because of primary providers delay in facilitating the needed treatment, and the patient in question can file a legal case against the provider.
Our healthcare system relies heavily on referrals. For some time the healthcare sector favored specialty over primary physicians (evident in the disproportion of primary providers we have) but evidence now compel us to look at the care delivery pyramid and amend necessary changes for better care delivery and efficiency.
The importance of referral is that it is not just the next step in care delivery, but for patients who may need desperate guidance and recovery, a referral will chart their health care course for better or worse.