Bad provider referral patterns come at a cost
While the healthcare market has evolved to better cater to consumers’ demands and offer specialized care, physicians are still referring patients in outdated ways. This costs health systems by increasingly sending patients to receive out-of-network services, according to a recent study by Kyruus, which surveyed 100 primary care providers and 100 specialists affiliated with U.S. health systems.
On average, providers estimated they send about 25 percent of their patients out of network, and almost half–45 percent–say they face difficulty determining in-network providers. Part of the problem may be that providers don’t have the tools they need to keep patients in network, particularly as health systems have become larger.
Over the last decade, booming M&A activity has given rise to larger and more complex provider networks that have also become more specialized. Providers now need more information to ensure appropriate referrals with better network visibility, according to the study.
The vast majority of providers indicate their health system has requirements around referring in network. While 84 percent of providers surveyed recognize these requirements, 79 percent still refer to patients to out-of-network providers, with 72 percent saying they usually refer to the same person for a given specialty.
“Understanding who is in-network and what their specific clinical areas of expertise are has been a long-standing challenge for physicians,” Erin Jospe, MD, chief medical officer at Kyruus, said in a press release. “This new research reaffirms the widespread need to empower physicians with better insights and capabilities, so they can make the best referrals for their patients and help guide their care more effectively.”
About a third of providers thought their out-of-network referrals could be avoided if they had access to more robust information about the providers in their network, but only 60 percent of PCPs had access to a provider directory curated for their health system. Many providers–42 percent–also said they feel they are not practicing at the top of their license, hindering professional satisfaction and engagement.
In addition to lower provider engagement, out-of-network services can have an impact on patients, as well.
"Transparency is such an important factor in patient satisfaction, and yet with an out-of-network referral, cost is often unclear, risking significant unforeseen out of pocket patient expense," Jospe told HealthExec. "There are increased challenges in communication between providers when they are not within the same network, and with those breakdowns in communication, you have the potential for poor coordination of care, provider frustration and operational inefficiencies. For example, poor care coordination can result in duplicate tests being ordered, scheduling delays while records are waited on, follow-up not occurring in a timely fashion or perhaps not at all. This lack of coordination has real ramifications to patient safety, again negatively impacting care quality and the overall patient experience."
Hospital-owned providers were more likely (76 percent) to have access to a provider directory from their health systems. By comparison, 33 percent of medical centers and 44 percent of solo private practices say they have access.
More than a third of healthcare consumers say they want referrals from a healthcare provider rather than relying on independent research. Most providers or their office staff do refer to a specific provider, while others refer to a practice group or specialty, which still leaves some of the burden on the patient.
Providers tend to refer to the same provider for specialties, potentially missing opportunities to factor in network availability, including connecting patients with a provider that can see them sooner, according to the study. More information about in-network providers could avoid 34 percent of out-of-network referrals, providers estimate.
"With every movement of the patient outside of the network, there is a risk of the patient being lost to the network moving forward," Jospe told HealthExec. "The health system loses the chance to cultivate customer loyalty in this failure to effectively retain them."
When it comes to retaining patients, 64 percent providers recognize that making another appointment before the patient leaves the office is important, but only 42 percent of patients leave the office with an appointment, the study found. When appointments are booked, 60 percent of providers do it by phone.
“The gap between perceived value of scheduling the appointment and realization of this task may be a result of inefficiencies in the booking process,” the study reads.
Furthermore, communication across the health system is lacking, as 60 percent of providers say they don’t always know if their patient was seen by a specialist or next steps in the care plan.
“Having insights on referral appropriateness is key to minimizing re-referrals that drive cost and poor patient experience,” the study said.
Health systems can take several steps to close the loopholes that can leave patients with out-of-network services, including improving provider satisfaction and developing tools, technology and resources for providers to have more patient outcomes data. Using analytics and education about the health system can also improve provider referral practices, according to Kyruus.
“As provider networks continue to grow, they can become increasingly opaque to their own provider members,” the study concluded. “Providing access to a granular view of provider capabilities could encourage in-network referrals. Failure to meet provider needs for this detailed information may lead to suboptimal and/or out of network referrals.”
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."