The Treatspace Referral Management Blog

Updated February 2017

In almost every speech given in 2016, Andy Slavitt, the former Acting Administrator for the Centers for Medicare and Medicaid Services (CMS), has emphasised the priority of closing referral loops to strengthen patient care coordination.

Independent practices have less than a year to prepare for newly developed value-based care reimbursement guidelines. The option to test the quality payment program under MIPS and MACRA will no longer be in play beginning in 2018. In view of the challenging financial penalties of value-based payment, many practice leaders are struggling to find an efficient way to close referral loops.

It would be easier to coordinate team-based medical care on facebook rather than with EHR systems.

- John Halamka, CIO | Beth Israel Deaconess Medical Center and co-chair of the federal HIT Standards Committee, at the HIMSS conference in March 2016¹

EHRs aren’t enough

A common misconception is that an electronic health record (EHR) can close referral loops and provide high-performance referral management for primary care practices. However, not long after EHRs were implemented, users quickly realized that EHRs alone are not able to establish a pipeline that allows data to flow between PCPs and specialists from different organizations.²

Accountability in health care often means that primary care practices are liable for the cost and quality of a patient’s care across the continuum of care. In the old, diminishing fee-for-service reimbursement system, practices were only reimbursed based on actions within their own office.

Now, in new reimbursement models like ACOs, PCMHs, risk-based contracting, and alternative payment models, shared accountability is king.

“The idea that you are accountable for what happens after people leave your office is no longer just a philosophical discussion. It's dollars and cents.”¹

The New England Journal of Medicine describes the traditional patient referral process as a perilous journey [1]. Right off the bat, only half of patients show up to their referred specialty physician appointments [2].

In fact, the referral process is so fragmented that even when patients do show up to their specialist appointments, only 32% of specialists will receive clinical information from the PCP prior to seeing the referred patient. [3]

A tsunami of change is shifting the healthcare reimbursement system towards value-based care.

As a result of legislation passed in 2015, called MACRA, Medicare is supercharging its emphasis on value-based payments and the first performance year will be 2017. As a result, the way medical practices manage referrals will impact their revenue.

“Providers that hope to succeed under the new payment methodology need to begin making changes now.“
- Dave Wofford | Healthcare Financial Management Association