'Arming' providers with the right information — Why clinical focus matters

Graham Gardner, Co-Founder and CEO of Kyruus and Amitabh Chandra, Malcolm Wiener Professor of Social Policy & Director of Health Policy Research at Harvard Kennedy School of Government and Member of Kyruus Strategic Advisory Board. - Print  | 

Medicine is a team sport. Primary care providers, the quarterbacks of patient care, rely on a network of specialist colleagues to provide the management of conditions that require more in-depth expertise.

Historically, PCPs assembled their own referral networks – building relationships over time as they progressed through training and into clinical practice. These relationships were valuable – not only in their ability to support the care of patients who require specialized care, but also because they reduced the burden for patients shopping around for a specialist. A specialist will always make time to accommodate an urgent patient from a PCP with whom they share patients, but they may not do that for a PCP they don't have a relationship with. However, despite these longstanding patterns, several factors have increasingly compromised the effectiveness of traditional referral relationships.

One of the key trends hindering the effectiveness of traditional referral behaviors is the hyper-specialization of medicine. There is no longer such a thing as a "go-to orthopod." Instead, many orthopedic surgeons now focus on specific anatomies such as hand, elbow, shoulder, spine, foot and ankle, knees, hips, etc. No longer can a special relationship with a single orthopedic colleague ensure access to the right kind of specialty care and too often, patients that are sent to a specialist need to be re-referred to a partner that actually does focus on that specific condition or procedure. In fact, surveys of specialists suggest that 25% of referrals are clinically inappropriate – resulting in unnecessary waiting and co-pays for patients while gumming up access for appropriate patients.1

Recent research by our team suggests that the precise "focus" of a surgeon matters for patient outcomes like survival – even when we compare surgeons within the same hospital and independent of their case volume. The study of selected surgical procedures performed by more than 25,000 surgeons in the US showed that a surgeon that performs a narrow range of procedures has better outcomes than one that operates across a broad spectrum of conditions and procedures. As an example, the relative risk reduction for a surgeon in the top quartile for heart valve replacements was 46% compared to their peers in the lowest quartile of focus. The relative risk reduction was a comparable 42% for surgeons in the top and bottom quartile of focus on abdominal aortic aneurysm repair.2 In other words, fewer patients die when care is directed to a provider who focuses on that precise condition.

A second trend working against using referral networks that were built the traditional way, is the fluidity of provider affiliations at a time when many PCPs no longer visit the hospital and interact with their colleagues on a regular basis. While hospitalists gain familiarity with hospital-based providers quickly through the intensity of their interactions, PCPs in the community must increasingly rely on relationships that were developed during training but ultimately grow stale. As health networks evolve over time – through mergers, acquisitions, and affiliations – identifying the right in-network providers becomes increasingly difficult for busy PCPs in the community. While some health systems send out information about new providers and/or arrange for in-person "dates," it is easier for PCPs to keep pre-existing relationships and referral patterns. As a result, PCPs have limited awareness about comparable specialists that might be newer and more available. Patients experience long wait times - leading to possible patient leakage - while the health system suffers from the underutilization of new providers.

Weak visibility into the composition of provider networks compounds these issues. A recent report found that many PCPs are unable to access reliable information about which providers are in their networks - much less the specific clinical areas of expertise of these colleagues. This information gap increases the risk that patients may be referred out of network. As evidence, 58% of PCPs who don't always comply with in-network referral requirements cited a lack of clinical expertise within their networks as a key reason. Even when efforts are made to keep care within their defined provider network, 50% of PCPs surveyed said that lack of provider availability information is a challenge in the referral process.3 Specialists receiving referrals cite the same challenge with 62% of them attributing the misdirection of patients to the wrong type of specialist to the lack of reliable information about specialists.4

The inability to coordinate care within a network can have meaningful operational and financial implications for a health system as care leaks out of network. The cost of this is even larger in an era of Accountable Care Organizations and Medical Homes. But even more importantly, the inability to find and more precisely match patients to the "right" provider can have profound consequences on clinical outcomes. Without adequate information about their colleagues, PCPs are handicapped in their ability to fulfill their commitment to those that rely on their counsel.

But these problems also yield a simple solution, which suggests that defining and publishing each provider's unique clinical scope of practice is essential to ensuring that patients are managed by providers best suited for their condition. PCPs - the trusted quarterbacks of their patients' care - can use these guides to refer patients for specialist care. This would not only save money for health systems but also save lives for those that trust us with the care.

1 Kyruus, "Physician Referral Survey," 2014.
2 Nikhil R. Sahni, Maurice Dalton, David M. Cutler, John D. Birkmeyer, and Amitabh Chandra, "Surgeon specialization and operative mortality in United States: retrospective analysis," BMJ 2016; 354:i3571.
3 Kyruus, "Primary Care Referral Behavior Report," 2016.
4 Kyruus, "Physician Referral Survey," 2014.

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