Why PCPs Don't Always Refer to Your Preferred Specialist

Three clinician beliefs and habits that make specialty care guidance difficult for plans

Specialty care costs are high—and growing. Physician compensation is 46% higher for specialists than for PCPs, and specialist visits increased by 14% from 2012 to 2016 (while PCP office visits declined by 18%). Much of this spending is inadvertently at the discretion of the PCPs making referrals, with many missed opportunities to improve efficiency while maintaining high-quality patient care:

  • Unnecessary referrals for conditions that can be managed in primary care
  • Out-of-network referrals from a member’s specific product coverage
  • Referrals to low-value (high-cost and low-quality) specialists

Plans currently try to share information with PCPs on high-value referral patterns through network design, provider directories, and online provider portals, but there is still a lot of medical spend wasted on inappropriate specialty referrals.

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