Closing the Loop on Referral Management

ACOs that have been in this game for more than two years know how important referrals are and have made referral management within a high value network a top priority.

Joe Francis, VP Sales

Joe Francis, VP Sales Follow

June 3, 2019

Specialist physician looking at an xray while meeting with a patient.

Imagine going to a specialist who walks into the exam room and says, “Hello. It’s nice to meet you. I’ve just finished reading the notes from your last PCP visit and reviewed your labs. Let’s talk a little more about the specific symptoms you’re having.” Then, upon leaving the room says, “My nurse will send your prescription to your pharmacy and I’ll send a summary of our visit to your PCP. Feel free to call me or your PCP with any further questions.”

If you’re one of the rare individuals who has experienced this scenario, then you can officially say that you understand the concept of a closed loop referral from a patient’s perspective. And it’s indeed, rare. In fact, a significant number of patients still leave their PCP’s office or the Emergency Room with their “referral” being the name and phone number of a specialist on a piece of paper and perhaps a fax sent to the specialist. If the patient does follow up with the specialist, it’s a high probability the specialist won’t have the patient’s relevant health records unless the specialist is part of the same health system as the PCP and on a common Electronic Health Record (EHR). And even then, he or she will only have access to the information generated by the physicians, hospitals, labs or other entities using that particular EHR version and associated with that particular network.

Fortunately, the patient experience of a closed loop referral will eventually become the typical experience rather than the exception. As the industry continues its transition to value based care (VBC), organizations like ACOs and other value based contract models cannot succeed without closed loop referrals. And the VBC transition continues to accelerate, as noted by the Health Care Payment Learning and Action Network (HCP LAN), a public-private partnership launched by the Department of Health and Human Services (DHHS) in 2015, in this proof report. “Almost 34% of healthcare payments in 2017 were made through alternative payment models – that is, shared-savings, shared-risk, bundled payments, or population-based payments.” Additionally, Fee-for-Service (FFS) reimbursement decreased by 34%.

Financial investments to improve and report on quality, identify the sickest patients and implement care management processes to effectively manage those patients have been the biggest priorities so far for most accountable care organizations. These initiatives are a great start to managing risk but there’s a vital missing link between these two pieces, namely referral management between primary care and specialists and other community providers. With chronic conditions on the rise, identifying and improving access to high value specialists who understand their role on the value based care team is quickly moving from a ‘nice to have’ to a ‘must have’. ACOs that have been in this game for more than two years know how important referrals are and have made referral management within a high value network a top priority.

Interested in learning more about the impact referral management has on total medical cost? Download the whitepaper “An ACO Success Story: The Path to Market Leadership” and learn how Key Physicians, an Independent Physician Association (IPA) in Raleigh, NC has thrived. They took an unconventional approach by leveraging technology to coordinate care within and high value provider network that allowed them to evolve from a struggling IPA to market dominance in value based care.

Joe Francis, VP Sales

When Joe's not driving all aspects of business development at Infina Connect, he's hanging out at the beach with his wife and kids, surfing or flying airplanes. Joe is beyond passionate about changing healthcare and the impact referral coordination within high value networks can have on the patient experience, clinical outcomes, and affordability.