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Contents

6.E.1. The Problem
6.E.2. Intervention #1: The Referral Agreement
   6.E.2.a. Key Elements
   6.E.2.b. Example
6.E.3. Intervention #2: The Referral Expert
References

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Rapid Referral Programs
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6.E.1. The Problem

Both the ease and the speed of the specialist referral process are major concerns for patients and their primary care providers (PCP). For patients, problems getting a referral are reason enough for dissatisfaction. Patients having trouble getting referrals reported the greatest level of distrust, lack of confidence, and dissatisfaction with their PCP.¹

Compounding their frustration is the possibility of delays in care, which generates greater anxiety and contributes to a greater risk of adverse clinical outcomes. This problem is especially salient for members with chronic illnesses, who typically require regular visits with one or more specialists.

In addition, patients unclear on the process or disconcerted by the wait often have little choice but to call their clinician's office to seek clarification and assistance, which can add to their frustration (and increases the workload for the office). Some patients end up seeking care elsewhere (e.g., emergency departments and urgent care clinics), and become "no-shows" for the eventual referral appointment.

Specialist referrals are a serious problem for some health plan members. In response to the following question "How often did you get an appointment to see a specialist as soon as you needed?," 22 percent of adult enrollees in Medicaid health plans responded "never" or "sometimes."²

While several factors contribute to complaints about specialist referrals, one common problem is that physicians' offices are not set up to handle the referral process efficiently. In particular, they are not communicating well with the specialists, the health plans, or their patients.

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6.E.2. Intervention #1: The Referral Agreement

Rapid referral programs include a host of strategies intended to reduce the delays associated with specialty referrals and increase satisfaction among patients and doctors. One useful approach is to improve communication between the PCP and the specialist through a referral agreement. The goals of a referral agreement include the following:

• Speeding the process by which a PCP makes a referral to a specialist.
• Reducing the amount of time between the initiation of a referral and the date of the patient's appointment with the specialist.
• Providing the PCP with decision support for the referral decision (typically in the form of guidelines).
• Improving the flow of information among the PCP, the specialist, and the patient.

When implemented effectively, this program should result in earlier diagnoses, reduced "no-show rates" at specialists, better patient outcomes, and greater patient satisfaction.

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6.E.2.a. Key Elements

The referral agreements are meant to make the process more systematic and more responsive by helping PCPs make appropriate referral decisions and clarifying the expectations for information on both ends. In general, referral agreements require the following elements:²

• Joint development of guidelines by a small group of PCPs and specialists who are willing to think of themselves as creating a cohesive system of care. The purpose of the guidelines is to identify which clinical conditions the PCPs should manage themselves and which should be referred to the specialists.
• An explanation of the benefits to PCPs (e.g., shorter waiting times for patients, more timely and complete information from the specialist). While specialists may get fewer referrals, the benefits to them are more obvious: more effective care for patients, higher relative value units (RVUs), and more referred patients who have had a complete work-up.
• A referral process that involves the patient in decision making. This process should be designed to keep the patient informed, identify the work-up required before the specialist appointment, inspect the completeness of the work-up, and make sure that both the specialist and the PCP receive timely information. An electronic referral system can facilitate this process.
• An evaluation of the new referral process based on specific measures, such as waiting time for an appointment, physician compliance with the guidelines, and patient satisfaction with involvement in the referral process.

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6.E.2.b. Example

An example of an electronic referral system can be found at The University Hospitals of Leicester, England, which have implemented a Web-based electronic referral system for cancer. While this project applies to the UK's National Health System, which clearly differs in many ways from the system of care in the U.S., it is still illustrative of the improvements that technology can make, in this instance by linking decision support with an electronic referral process.

When the clinician opens the Early Referrals Application (ERA), he or she chooses from among 12 different cancers, and then selects the electronic referral option. Once there, the physician is guided through a series of three screens:

• Data entry: This page collects the information needed for the decision support module (e.g., for breast cancer, it has a series of check boxes to describe lumps, skin changes, pain, etc.).
• Recommendations: Using the data entered in the first screen, this page indicates whether a referral is recommended and, if appropriate, the degree of urgency. If the physician chooses the referral button, the final screen appears.
• Referral form: This form captures the patient information needed by the specialist being given the referral. Because of the link to an electronic medical record system, much of the demographic information will already be inserted. When the physician adds additional comments or notes and clicks on Email Referral, the form is sent to the referral hospital.

Learn more: University Hospitals of Leicester NHS. . Accessed July 7, 2017.

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6.E.3. Intervention #2: The Referral Expert

Doctors and group practices that care for patients covered by multiple plans and insurers often expend a great deal of time and energy getting approvals from the plan/insurer for referrals to specialists, hospital admissions, tests, and procedures.³ This task has become increasingly complex as the number of insurance products has grown, since each one has its own rules and requirements.

One way to address this problem is for a group practice to develop a referral expert in the form of a person, a computer system, or a combination of the two that is responsible for tracking and managing each plan's requirements. This strategy helps to increase the speed of approvals, which has multiple benefits.

• For the patient, it can mean reduced or eliminated delays for referrals, tests, and procedures, which increases satisfaction with care.⁴
• For providers, health plans, and payers, quicker approvals save costs associated with the phone and paper-based approval processes,⁵ as well as costs resulting from grievances and complaints.

A referral expert would expedite insurance authorization by doing the following:⁶

• Knowing which plans require authorizations.
• Staying abreast of changes in plan regulations.
• Knowing what actions to take when referrals are denied.

However, this intervention can be as simple as developing matrices (or ideally, a database) of referral requirements, co-pays, etc., for each insurance product and designating a person to keep the matrix or database up-to-date.

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References

1. Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA 1999;282(3):261-6.
2. National CAHPS Benchmarking Database. Comparative Data: Health Plans, Adult Medicaid Survey 5.0, 2014. Available at . Accessed on July 28, 2015.
3. Preston SH. Wrestling with the managed care octopus, Part 3. Get insurance authorizations faster. Med Econ 1999;76(9):117-8, 121-2, 124 passim.
4. Chan TC, T. C., S. R. Hayden SR, Schwartz B, et al. (1997). Patients satisfaction when denied authorization for emergency department care by their managed care plan. J Emerg Med 1997;15(5):611-6.
5. New England Healthcare EDI Network. Progress Report: Reaping the Benefits of Administrative Simplification; 2002. Available at:. Accessed April 22, 2008.
6. Preston SH. Wrestling with the managed care octopus, Part 3. Get insurance authorizations faster. Med Econ 1999;76(9):117-8, 121-2, 124 passim.

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