Why the traditional approach to patient referral needs to change, and how

“In the traditional model of how patients are referred to specialists, there is a lack of transparency into the quality and cost of care they will receive. Referring physicians and APPs have no true metrics to decide if their patient will be appropriately treated,” says Paul Krakovitz, Interim Regional President, Nevada and VP & Chief Medical Officer, Specialty-Based Care, Intermountain Healthcare.

Krakovitz is a speaker at the marcus evans National Healthcare CMO Summit 2021.

What is missing in value-based care?

The piece that is missing in value-based care is around patient experience, consumerism. Physicians have improved in patient experience scores. However, true consumerism metrics, like those seen in service industries, are lacking. Further, we are in our infancy of caring for patients when it is convenient for them.

Value-based care is about getting the highest quality care and experience at the most affordable cost. The way patients are referred to specialists, outside of word of mouth, there is little information to know if their patient will receive the appropriate treatment.

The pandemic has put a lot of financial pressure on patients, and changed the way they look at healthcare. There is a need for a value-based system more than ever. With the fee-for-service model, most patients were protected against high costs as they would be covered by their insurance, but that changed with high-deductible plans. Healthcare is just not affordable anymore for most people.

What steps has Intermountain Healthcare taken to address this gap?

We began a journey to establish high-value specialty care networks. As consumers of healthcare, when patients are referred into a high-value network, they know that their physician has been vetted by peers, and is able to provide high-quality affordable care. It is really about metrics and benchmarking against other physicians, quality, safety, patient experience, as well as appropriately measured cost. Transparency for patients and referring physicians with understandable metrics to compare healthcare providers. Transparency for specialists to understand the expectations of agreed upon standard of care.

Why is it important that peer groups of specialists define the metrics for each specialty?

Those who are the closest to the work are the most capable of defining it. No one else understands the quality and appropriateness of care to the same degree as similarly trained specialists. Additionally, having a full complement of team members to evaluate further improves these metrics (finance, quality officers, referring physicians).

What does this mean for Chief Medical Officers?

We have been talking for decades about the right patient, right place, right time, right physician, and fill in more “rights.” When it comes to referrals, it has always been a question of when do you refer, and who do you refer to. By developing a high-value network that is accepted by primary care, the specialists, as well as the payers, this helps get transparency for patients. The goal of a high-value network is not to make this an exclusionary process. Ideally, it will allow providers to see their metrics, understand patient expectations, and better meet their needs. The goal is transparency on both sides, for referring physicians to feel confident they are placing patients into the hands of the appropriate specialists, and for patients to feel very comfortable and confident with the healthcare system.

As more organizations transition to value-based care, this is an area that more Chief Medical Officers need to consider. There is lack of trust and transparency in healthcare. The whole point of a high-value network is to have confidence in the system. It is about teamwork. What is missing here is teamwork and transparency between primary care and specialists, and how to appropriately refer patients. That is what we are addressing. When a physician refers a patient to a cardiologist now, most likely they had a choice of 45 cardiologists in the EHR, and they simply picked the only cardiologist they knew, maybe someone they had met in a cafeteria one day. That might be the only data point they have. This has to change.