I need your help.
I’m trying to figure out how to get rid of something that’s terribly broken in our process of taking care of patients, and I can’t do it alone.
It’s time to kill the referrals process, get rid of them altogether.
Every day, a huge proportion of the messages we receive through the electronic health record are requests for us to “put in a referral.”
Patient has low back pain, has scheduled an appointment to see a rehab sports medicine doctor, please enter referral.
Patient is in their dermatologist’s office, and they’ve been told they cannot be seen until we fax over a referral, immediately. If not done in the next 15 minutes, their appointment will be canceled, and they will be told it is your fault.
Patient saw their cardiologist this morning, who ordered a stress test, an echocardiogram, and a cardiac calcium scan, but they have been told that you as the primary care doctor need to enter the referrals for these tests to be covered by insurance.
Now, to many people, this doesn’t seem like such a big deal, but the ridiculous nature of this work is that it requires no medical training, no real brainpower, but often quite a bit of clicking in the electronic health record, and a lot of our time.
Undoubtedly this is contributing to the burnout we see happening across the spectrum of care providers.
In our electronic health record, you need to go to the order section in the telephone encounter where you got the request for the referral, type in the specifics of the referral (such as consult to adult dermatology, or echocardiogram), then select a provider, then the number of visits you are authorizing (as if we somehow magically knew how many visits it will take), then whether this is an internal referral within our organization or to an outside provider, then the justification for selecting an outside provider if chosen, then type a clinical reason for the referral, then find an appropriate ICD-10 code that matches the reason for the underlying diagnosis for which they’re getting this consult or procedure done.
Now I’m exhausted, and I’ve not really provided much (or any) care, and there’s another referral waiting to be processed right behind this one.
One of my colleagues got so sick of this process, that when he gets sent requests for something he didn’t order, that maybe the patient scheduled on their own, he devised a system that essentially reflected the disdain with which he viewed this process.
When he got an urgent request from the front desk staff saying “Patient is in their podiatrist’s office and needs a referral, routine visit,” he would enter the most banal diagnosis he could find, and writes a skeletal clinical reason.
Reason for referral: foot issues.
We jokingly collected a whole bunch of these:
Reason to see a dermatologist: they have skin.
Wants to see a cardiologist: has a heart.
It doesn’t matter, no one reads them, they go nowhere but to the insurance company.
Where did this whole concept of a referral come from, why do we need them, do they serve any purpose, and would we be much better off if they just went away?
When we started out before insurance rules and the burdens of the electronic health record, it made more sense to create some sort of a form to communicate with our specialist colleagues about the reasons why we were sending someone to see them.
Dr. Smith, this patient has me stumped, I’m not quite sure what to do about managing problem X, can you offer an opinion, lend me some of your expertise, make some suggestions about what we might try next.
These days, this functionality would be replaced by the fact that we all live in the same electronic health record, our notes are all there for everyone to see, and it seems pretty obvious why we’re sending someone over to see a specialist.
What remains in the referral process now is just an administrative barrier set up by the insurance companies, a way for them to create some sort of gatekeeping function where they allow patients only so many visits per year to see a specialist, and only so many physical therapy appointments for their lower back pain before they get to charge more.
I understand it’s in their interest to control costs, but why should this be something that we need to be in the middle of? Perhaps we should have the insurer’s office process the referral, let them authorize the visits, why do I or my office staff need to be any part of this process at all?
I can send a message to one of my ENT colleagues that I’m sending a patient over to see them for refractory sinusitis or unrelenting vertigo, and we can skip the middleman altogether.
So why do I need your help?
This process is just emblematic of all the things that are wrong with how the whole process of delivering healthcare has been set up, how it’s been transformed into a bunch of tasks that have little to do with healthcare, but mostly to do with business and bureaucracy, that makes us all so burned out trying to take care of patients.
If we are going to chip away at all the things that are wrong with our healthcare system, and build a better environment in which to practice and take care of our patients, we need to stand up as a group and say enough is enough.
Somewhere in our contract negotiations with the large insurance companies there was inserted language that says we agree to place referrals and limit the number of times people see subspecialists or other limits on the kind of access to care they need, but we need to say that this is not the point of healthcare, the point of healthcare is to let us take care of our patients.
I by myself can’t just say, no, I’m not going to fill out referrals anymore. My practice alone cannot get together and decide we’re not going to fill out referrals anymore. Even at the level of our institution, a large academic medical center, if I got everyone here to agree to go on strike, we might begin to be able to make inroads against the people who have foisted this system upon us. But I suspect that the insurers would just say well, we will get someone else who is eager for the business who would be willing to do this then, or else they might threaten to lower the rates they’re reimbursing us at.
And just passing this work on to non-physician staff at our office is not the answer. Not only is this beyond the “scope of practice” of these staff members, as the system will only allow MD’s or NP’s to enter referrals. But I consider them such a waste of time that I would never want them to have to do this useless, mindless work that adds no value to the care of our patients.
No, we need to rise up as a group. We need to begin to say that entering a referral and so many other things that we do that get in the way of caring for patients, that stand between us and our patients, that force us to sit and type in an exam room instead of sitting and holding our patient’s hands, these things and so many others need to go away.
We allowed these systems to be layered upon us, to weigh us down so that we arrive home at the end of the day battered and broken.
If you want to be liberated, if we truly want to build a patient-centered, caring healthcare system that puts our patients first and those that deliver that care second, we need to take a stand.
This seems like a good thing to start with, one thing we could ask for, demand, that might make a real difference in terms of provider burnout and make us once again love coming to work to do the caring we were trained to do.
Help me figure out how we can rise up as a group and put an end to this mindless task that no one should really have to do.
Let’s find a way.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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