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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