A lot of population health management has focused on primary care, but the industry hasn’t made significant strides in specialty care—even though it drives the bulk of health care spending.
That’s because involving specialists in value-based care is hard. Not only is specialty care a more diverse space, but it's also more tied to traditional fee-for-service reimbursement and episodic care delivery. We’ve previously discussed how engaging specialists in accurate HCC capture is a ‘no-regrets’ opportunity in this hybrid financial incentive state—but what ambitious, yet feasible behavior changes remain for specialists?
In this series, we discuss three near-term strategies to engage specialists in improving population health—even with significant fee-for-service reimbursement. These strategies aim to reduce low-value referrals to specialty care and ensure patients receive the right level of care at the right time.
Not every referral is a good referral. Low-value referrals waste specialist capacity and inflate health care costs. Establishing referral considerations are a low-cost way to prevent low-value referrals.
What we mean: Evidence-based referral considerations aim to inform clinical decision-making, such as a best practice advisory in the EHR or a short list of guiding questions. These help avoid care delays and misuse of specialist time.
What we don’t mean: Note we’re not saying referral protocols here. That’s intentional. Multiple executives told us protocols can be too broad, too specific, not updated, hard to enforce, and doctors just don’t have time. It’s impossible to capture the level of patient diversity and complexity to direct appropriate clinical triage in every situation.
Target specialties with limited access for patients—they could be inundated with low-value referrals. These specialists also have intrinsic motivation to equip PCPs to treat these needs when they can.
For example, Brigham and Women’s Hospital’s dermatology department was receiving an overwhelming number of low-value referrals specifically for acne. So, they built a best practice advisory into their EHR. If a physician orders an acne referral, it asks whether the case is mild, moderate, or severe, with accompanying pictures. For mild and moderate cases, it offers a list of recommended therapies for the referring physician to consider ordering rather than making a referral. The referring physician can override the notification and send the referral anyway (or initiate treatment and send the referral), but the tool eliminates the low-value referral as the default option.
Brigham and Women’s conducted a prospective cohort study on this tool across 260 patients and 33 primary care sites from March 2017-2018. It found that the best practice advisory resulted in referral cancellation in 13.5% of cases and treatment initiation by the referring physician in 19.6% of cases.
The purpose of referral considerations is to empower referring physicians to make informed care planning decisions. Pseudonymed Rosemary Health created guiding questions to help PCPs prioritize high-risk skin cancer screenings. For dermatology patients with a prior history of skin cancer, Rosemary’s tool asks the referring physician three questions:
Leadership emphasizes that the point of the tool is not to give the PCP the “right answer” for treatment. Instead, it respects the autonomy of PCPs to treat higher-acuity cases and prioritizes for dermatologists which referrals are high-risk and necessary for urgent scheduling.
New York-based multispecialty group Crystal Run Healthcare includes representative physicians from primary care and all their specialties to determine clinical triage guidelines. They organize this work into two committee types: single-specialty committees for specialty-specific conditions and multi-specialty committees for cross-specialty conditions. These committees meet over time to iterate and increase exposure to new physicians. And leadership has noted that the process of facilitating collaboration and culture building between physicians is just as valuable as the guidelines themselves.
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This expert insight series is sponsored by Episource, an Advisory Board member organization. Representatives of Episource helped select the topics and issues addressed. Advisory Board experts wrote the post, maintained final editorial approval, and conducted the underlying research independently and objectively. Advisory Board does not endorse any company, organization, product or brand mentioned herein.
David G. Li et al, “Evaluation of Point-of-Care Decision Support for Adult Acne Treatment by Primary Care Clinicians,” JAMA dermatology 156, no. 5 (2020): 538-544, doi:10.1001/jamadermatol.2020.0135.
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