How Referrals Work Today

You would be hard pressed to understand the current landscape of specialty referrals without first reading the 2011 report by the Milbank Quarterly called Dropping the Baton: Specialty Referrals in the United States. It covers pretty much everything – from the history of referrals to the current processes – but most insightfully, the ongoing challenges that persist in the current system.

It’s a dense read (the pdf is 30 pages) and can be intimidating to wade through. But just because it covers research material from over nearly four decades in five search databases doesn’t mean it has to be inaccessible! Below is a high level summary which condenses what’s not working, and why.

In the U.S., more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits.

Referrals are the link between primary and specialty care. Yet despite this frequency, the referral process itself has been a great frustration for years. The transformation to value-based healthcare is well underway and at the core of this system comes a focus shift from volume and quantity of patients to the achievement of better health outcomes.

The Referral Process:

“The referral process can be divided into three components: referral decision making, care coordination, and access to specialty care. Our literature review provides evidence for deficiencies in each of these components.”

Referral Decision Making: The referral process begins with a physician’s decision to refer their patient to a specialist. This decision needs to be appropriate, meaning the patient needs the procedure and the correct specialist has been identified. The decision also needs to be timely, meaning it isn’t too late to make an impact.
Studies Show:

  • Over-referrals range widely from .7 to 65% – where patients are being referred when they shouldn’t be or are being referred inappropriately
  • Under-referrals, which attract less attention, range from 19 to 87% – where patients aren’t being referred to a specialist when they should be
  • Late referrals are associated with worse health outcomes and studies indicated up to 80% of patients are referred late

Care Coordination: Tracking referrals is key to ensuring that patients actually see the specialist. Then, the specialist needs the right information to provide the proper care. Effective information transfer and referral tracking are two areas that have been found to be in serious need of repair. Improving care coordination includes transferring relevant information to the specialist, such as laboratory and imaging results. There also needs to be post-specialist evaluation that transfers findings and follow-up recommendations from the specialist to the PCP. Integration between key stakeholders is key, meaning that the PCP and specialist should agree on the management plan and the role of the specialist throughout.
Studies Show:

  • 25-50% of referring physicians do not know whether their patients actually see the specialist they are referred to
  • Poor referral tracking leads to inappropriate re-referrals, inefficient care, worse patient satisfaction and malpractice lawsuits
  • PCPs and specialists cite the lack of effective information transfer as one of the greatest problems in the referral process
  • Up to 45 % of referrals result in no communication from the specialist back to the referring provider
  • Approximately one-quarter of U.S. patients report that the results and records from one provider did not reach another provider in time for their appointment – and when the information is finally sent, if sent at all, it is frequently late
  • One study showed 25% of letters from specialists were not timely enough to “affect decisions” and noted that 50% of referring physicians were dissatisfied with the timeliness of specialists’ feedback

Access to Specialty Care: Access to care is about ensuring that the patient is able to actually achieve an appointment with the specialist.Studies Show:

  • Access to timely specialist care is a growing problem, especially in underserved populations
  • Poor access is associated with worse health outcomes

Milbank Quarterly’s Conclusion:

The current state of the specialty-referral process in the U.S. provides substantial opportunities for improvement, as there are breakdowns and inefficiencies in all its components. When we take a closer look at the appropriateness of referral decisions, we find that under-referrals and over-referrals are rampant.

But there are even instances where repeat referrals are being given because the initial referral didn’t solve the problem. To make matters worse, even the referrals that are made are often too late and health outcomes suffer as a result. These factors have led to notable legal issues; for example, one study showed that 26% of malpractice claims pertaining to a missed or delayed diagnosis involving a failure to refer.

Improving the referral process deserves greater attention and many of the mechanisms to improve it, including use of IT and payment reform are promising. But no single change will address all the gaps, so we need rigorous evaluations of mechanisms to improve the process across care settings.

To learn how MyHealthDirect solves these problems read our free guide, Redefining Patient Access.