HTN Specialist Referral Discussion Readout
Insights from the live online referral discussion on Tuesday, Jan 11th, 2022
Last Tuesday, about 40 health innovators from the health tech nerds community came together to discuss challenges and solutions for the broken specialist referral process. (If you're not a member in HTN yet and want to connect with other health care innovators, it's definitely worth the monthly subscription.) We had participants from health plans, physicians, digital health providers, and health data & infrastructure companies sharing their thoughts and experiences on specialist referrals. In today's post, I want to summarize some of the main insights from our conversation.
Making the referral decision
A specialist referral process starts with two critical questions: Is a referral needed? If so, who should I refer the patient to? To make informed decisions on these, the physician will need robust data to base their decision on. Here are a few points that we discussed regarding the decision-making process.
Most referrals are based on tribal knowledge about specialists: Many information about specialists is shared via word-of-mouth or sporadic patient feedback. Learning the referral network is a rite-of-passage for every new doctor joining a new practice. It is often known that provider A is more likely to do procedure X and provider B is more likely to do procedure Y. Physicians rely on this word-of-mouth knowledge to steer their patients to the care they need. Making this data more accurate and based on evidence is the value proposition of companies like Ribbon Health, and it's also a priority for health plans to share this data with providers.
Referrals are a relationship business: Establishing a trusted relationship between a referring and referred provider is often crucial for a successful hand-off. Doctors care that their patients are in good hands when referred to another doctor. One virtual care company shared that they would do "warm" hand-offs, i.e., make the specialist provider join the video call to recreate the - "let me take you down the hall" experience. Building these relationships can be an effective patient aquisition strategy, also for digital health companies.
Better Metrics & Indicators: More and more solutions exist to help physicians make referral decisions. We discussed two metrics for a bit longer:
Cost data: Cost data is essential for health plans to help ACO providers steer their patients to more cost-effective providers. Sharing high-quality data and providing actionable analytics dashboards is critical for the success of such data-sharing programs.
Referral Quality: There is still a lack of great data around the quality of a referral, i.e., was the referral appropriate? What was the patient experience? Was the referred provider a match to the need of the patient?
E-consults are an effective way to avoid unnecessary referrals: Allowing general practitioners to consult with a specialist before making a referral is an effective way to increase the appropriateness of referrals. People shared that they had quite some success with these solutions. However, they only work in value-based-care models as fee-for-service doctors don't have an incentive to subscribe to these models.
Patient data transfer should work...
The next important step in the referral process is the transmission of patient data, and we spend some time discussing this topic. While Fax is still the method for data transfer in many practices, major regional and national networks for data exchange exist (i.e., direct messaging). In theory, it should be possible for providers to transmit patient records between their EHRs also from different vendors. In particular, providers & hospital systems using the major EHR vendors like Cerner, Epic, and athenahealth have built-in features to push & pull data through these data networks.
However, certain providers still have barriers to being part of this network. Not all EHRs support integration with the data exchanges, and setting up the integration often requires IT resources. These resources are particularly scarce for digital health startups, and integrating with national data exchanges is not always prioritized on their product roadmap. There are on-ramps to the data exchange networks that make it easier for providers like Health Gorilla or Commonwell, but they still need configuration and investment of resources.
... but no referral workflow exists.
Even if data sharing is possible in theory, sending and receiving patient data is only one part of the referral hand-off. A proper referral workflow involves more elements, for example:
patient data sharing authorization
acknowledgment that the provider received the referral
scheduling & availability checks
referral completion alerts
results of the referral & next actions for referring provider
Currently, no national network exists for this workflow (unlike what Surescripts does for prescriptions). During the session, there was common agreement that "closing the loop" was a significant problem. While sometimes the referring doctor gets data from the referred provider, it is often not actionable. "We either hear nothing from the specialist, or we get a 10 page PDF of the visit, while all I want to know is: did the patient see the provider? What were the diagnosis and treatments? And what is the next action required?".
Some organizations (ReferNow, Preferral) have tried to build this network, but no standard has emerged yet.
Paths to reformation: Who will build this?
So who will build the referral workflow network? We discussed several innovation paths during the session:
The regulator has to become active and impose a standard (like they've done in the Netherlands): this is probably the most effective approach, but it's also a crystal ball, and unclear whether the ONC or another governmental organization will pick this up.
A referral network will first be built in the digital health ecosystem & then expand to more traditional providers: Digital health providers care a lot about their customers' experience, and building first-class integrations with their partners is an essential part of this. However, many referrals flow from digital to traditional providers, making it hard to implement.
The patient will drive this, with patient-facing records: Unlikely to happen, as the experience shows that patient-facing solutions have little uptake.
It was also interesting to hear which organizations will be change agents and why they are incentivized to be early adopters for a potential solution.
Value-based care providers (ACO members, primary care providers, etc.): For providers operating under a value-based care model, referrals are a major point to reduce member costs. The referring providers have an incentive to reduce unnecessary referrals before lowering the utilization of their own services. Also, they can make an impact by referring to more cost-effective providers.
Digital Health Companies: On the referring (sending) end, digital health providers care a lot about the patient experience, also beyond their services but also the services and providers they are referring to/ partnering with. If they provide inaccurate referral data about costs, availability, or the patient experience falls off, they lose their patients' trust. However, to be full-service providers, they need to reach into the real world and partner with brick-and-mortar services. On the receiving end, there are more and more digital specialty providers struggling with high customer acquisition costs through traditional marketing channels. They increasingly see referrals as a better way to acquire patients. A pivotal argument to "sell" themselves to primary care providers is to provide a seamless experience to the referring provider by closing the loop.
Cost-efficient specialty providers: It's been quite hard to involve specialty providers in value-based care contracts. They often don't have anything to gain by reducing their fee-for-service claims. However, there are specialty groups that operate relatively cost-effectively, and they would benefit from becoming a preferred provider with an ACO to capture more demand for their services. To effectively partner with an ACO, having an end-to-end referral process in place is an essential argument for establishing the partnership.
These were just some of the many things discussed, and I am very grateful for everyone who showed up and shared their knowledge and experience. After the session was so successful, I plan to host these discussion groups more regularly: If you want to be notified about the next discussion group, please sign up here. Also, let me know if you would like to discuss a particular topic! I am open to your suggestions.