Attention PCP colleagues: We can do better with referrals

How many physicians know how many visits they are approving when referring to a specialist?

This was a germane question posed to me today. I first asked this question of myself as a junior faculty member, while busting the residents’ chops over the egregious numbers of referral visits they were approving. You see, as any good resident knows, being proactive in the referral department demonstrates skill in the art of “avoiding being bothered with repeated requests for *#%!. This is a skill that one either develops or does not, the latter being associated with career-long anguish. However, in my residency program (circa 1997), I was immersed in the wonderful world of managed care, teaching residents the difference between an HMO and a PPO, a heart attack and an acute case of thoracic shingles, a referral with too many visits and one with not enough. Too many = bad. Not enough = good work!

Many of these lessons evaporated with the volcanic changes that supplanted most HMOs with PPOs. Meaning that we went from gatekeepers to zookeepers (or maybe free-range doctors). The incentives to address the referral process gradually dissipated, and with it, the very term “referral” came to mean many things to many people. In fact, you can get a great metaphysical conversation going at a party (of geeky, middle-aged internists) with the question, “What is a referral?” The point is, it is probably going to start mattering again because risk contracts are back in vogue. Skin is in the game.

I posed this question to others who tolerate (barely) my inane queries. How many physicians know how many visits they are approving when they do a referral? One physician was surprised to learn that her referral person gave every patient ten visits. That’s a consult and nine follow-up visits for each referral without any need to send the patient back. Embarrassingly, my assistant let me know I’m routinely approving twelve visits as the standard number. Who knew? Heck, the patient won’t need to come back for a whole year! Mind you, many patients come back, either because they trust their PCP, or believe that their personal physician (say it like you’re asking for Grey Poupon mustard) needs to be in the loop. Or, the specialist, being of sound mind, simply tires of seeing the patient and directs them back to their PCP. In the best cases, the primary care provider and specialist actually talk (imagine that) and decide together the best course of action for the patient. Often, valuable information is gleaned from these conversations, and the patient is ultimately the beneficiary. My patients absolutely love to hear that I have personally talked with their specialist physician. However, this only happens a fraction of the time, because, we’re like, you know, busy.

Occasionally, things get ordered and checked, (things you wouldn’t have ordered or have never heard of) and, occasionally, the findings lead to more tests that lead to procedures that lead to — you get the point. It can lead patients down a path they never intended to follow, and the consequences can sometimes be dangerous. Moreover, if your patient has a health plan that puts you (that’s right — you) the PCP at risk, you are watching the warm blood drain out of your proverbial withhold. As risk contracts evolve, you might someday actually have to give money back to a health plan. Please repeat this several times silently to yourself and exhale deeply to help you relax.

It got me thinking: How many physicians actually know how many visits they’re approving when they do a referral? Do they even participate in that decision? Do primary care physicians still get angry when the specialist does not “return” the patient? Or do we assume that the patient will show up sooner or later?

Does anyone ever completely read a seven-page home health report? What about physical or occupational therapy reports? I’m not suggesting these are not valuable services for patients, in fact, sometimes they’re critical to recovery and quality of life. But sometimes, I wonder, what the heck am I approving when I mindlessly sign off on the myriad reports that cross my desk each day?

If ignorance is our defense, then we risk abdicating responsibility for our patients care. The solution is simple. Become inquisitive and ask yourself and your staff: How do we do referrals? How many visits am I willingly approving? How aware am I of my patient’s progress and when should I bring them back in to review the findings of others? Just asking the questions is probably a good place to start. Taking ownership of our patients best interests is the calling card of primary care and should be constantly maintained. Otherwise, we pass the responsibility for the care — and the associated costs — to others.

Thomas Gragnola is an internal medicine physician.

Image credit: Shutterstock.com

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