The Treatspace Referral Management Blog

Independent primary and speciality care practices have challenging years ahead. MACRA, MIPS, APMs, and the ACA are posing uncertain regulations and complicated payment models.

Despite this uncertainty, there is one thing that’s clear: independent practices must prepare to take on risk in order to stay profitable.

We sat down with Mark Kissinger, executive director of Genesis Medical Associates, to get the inside scoop on the challenges a large independent primary care practice faces in a value-based care and regulatory-driven world.

Communication between primary care physicians (PCPs) and the specialists they refer patients to is paramount to the overall best outcome for the patient. Much of the communication breakdown lies in outdated protocols and manual workflows that some organizations continue to employ. In the past, many physicians referred patients to various specialists, but never followed up on the recommendation. The patient was left to make their appointment with the specialist. In those cases, as high as 50% of the patients never made the appointments or followed up on the physician's recommendation. As illustrated, improving referral adherence shouldn't solely be the responsibility of the patient.

Former President Barack Obama and former Vice President Joe Biden both care a great deal about digital health technology systems. Even when they had less than two weeks left in the White House, physicians' ability to share patient health records digitally was top of mind — and on the same day, too!

According to Politico’s Morning eHealth newsletter, it was “the first time since the gods called this newsletter into existence [that] President Barack Obama and Vice President Joe Biden both talked on the same day about health IT”.

Effective communication is at the heart of success or failure in patient care. This is never more evident than in the relationship between Primary Care Physicians (PCPs) and the Specialists they refer their patients to for follow up examination. The best PCPs provide their patients with an ongoing relationship - they serve as a mentor or partner in health, helping patients understand their specific needs and making recommendations when appropriate. The benefit for patients in developing long-term relationships with their PCP is that they have a trusted physician who knows their history and can more easily assess warning symptoms for new ailments and lifestyle changes appropriate for health risks.

With coordination of care a major aspect of healthcare delivery, mistakes in the process lead to patient dissatisfaction or possibly worse. An excess of frustration in a patient's experience often leads them to pursue other primary care options. Fortunately, the emergence of electronic referral management technology can reduce errors significantly when referring to network specialists. The advantages of an electronic referral network can be seen and measured within those HCOs that adopted them early. As medical enterprises continue to implement the systems, better care coordination and happier patients will be the result.

An alarming number of primary care practices don’t have the staff required to proactively manage referrals. Medical assistant teams lack the capacity required to manage chronic care and quality programs, meet payor requirements, and hunt consult reports from specialists. As a result, these practices manually track referrals only when they are required to for regulatory requirements or internal referral initiatives.

The primary care practices that are proactively managing referrals are doing so with an overwhelming amount of expensive and manual workflow. Care coordinators are adding hundreds of hours to their workflow each month to ensure that patients are completing their appointment and that specialists are returning the clinical information needed for appropriate follow up.

In contrast, primary care practices that automate their referral workflow electronically are recovering up to 70% of their staff’s time [1] spent manually managing referrals.

Improved referral processes help practices meet value-based initiatives and devote time to programs that drive revenue—like preventative and chronic care management.

As the CDC sounds the alarm to increase awareness for colorectal cancer screening, primary care practices find that their EHRs can’t support the task of getting patients to complete colonoscopy referrals. In addition to the CDC, there is a growing focus by medical societies, advocacy organizations and media personalities like Katie Couric to ensure that adults over 50 get referred for colonoscopies to detect and prevent colorectal cancer. Awareness initiatives are critical because half of all patients referred for colonoscopies fail to complete the procedure.¹

The leading cause of blindness worldwide is diabetes. However, referral management makes a significant impact on saving the eyesight of diabetic patients. Most people who have diabetes for more than 20 years develop diabetic retinopathy¹, a condition where elevated blood sugar damages the blood vessels inside the retina. Over 7.7 million American adults have diabetic retinopathy today and that number is expected to double by 2050. The condition affects almost 30% of the US diabetic population over the age of 40² and causes up to 24,000 new cases of blindness in the US each year.

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