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Provider Experience, Chronic Disease Impact PCMH Referral Rates

Less experienced providers are more likely to hand out referrals to patients within the patient-centered medical home, indicates a new study.

By Jennifer Bresnick

- Patients with common chronic diseases, as well as those seen by less experienced providers, are more likely to receive specialty referrals than others being treated within the patient-centered medical home environment, according to an article published in the American Journal of Managed Care.

Patient-centered medical home and chronic disease management

While faculty clinicians at the Medical University of South Carolina’s (MUSC) academic internal medicine PCMH placed an average of 0.271 referrals per visit, residents operating under faculty supervision were nearly twice as likely to direct a patient to a specialist, delivering an average of 0.423 referrals per visit. 

Residents were also more likely to hand out more referrals per patient, and tended to request referrals for patients who were lower-income or more reliant on Medicare or Medicaid than those patients seen by faculty members.

Patients with higher chronic disease management needs, including those with COPD, peripheral vascular disease, depression, obesity, and substance abuse problems, received more referrals in general than their healthier counterparts.

Even though the patient-centered medical home encourages a team-based approach to comprehensive patient care, and actively invites specialty providers to collaborate with the primary care environment, referrals can produce confusion, duplication, patient data siloes, and extra expenses that may negatively impact care coordination.

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“Issues, including stresses on clinical volume, increased cost, fragmentation of care, and lack of process transparency associated with referral processes are well documented in the literature, even from as long ago as the 1960s when Kunkle and colleagues described the process as ‘needlessly inefficient,’” the authors wrote, citing a 1964 article in the Journal of the American Medical Association.

Medicare beneficiaries average two referrals per year and tend to visit an average of five specialists in addition to their primary care provider, which can create serious financial and cognitive burdens for patients and a revolving suite of clinicians.

“The involvement of more subspecialists increases the potential for miscommunication, additional testing, and polypharmacy, which may contribute to higher rates of ED visits and hospitalizations.  As we seek to optimize value in healthcare, we need to know how ambulatory referrals impact our goal of improving quality while lowering cost and improving the patient care experience,” the article says.

In order to help better understand referral rates, the authors also divided the patient population into five risk buckets based on the likelihood of hospital utilization. 

Unsurprisingly, perhaps, patients with higher risk scores were generally likely to receive more referrals.  These patients were more likely to suffer from multiple chronic diseases, which could have several different impacts on utilization, the authors suggested. 

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In addition to believing that these patients require more detailed, expert care in a particular field of clinical study, primary care providers may simply not have the time within a limited visit to give sufficient attention to each condition, preferring instead to let a specialist dedicate an entire appointment to each concern.

This strategy may aid certain patients, the article acknowledges, although many of the chronic diseases included in the study should generally be managed at the primary care level “except at the extremes of disease.” 

The pattern of higher complexity yielding more referrals holds true until patients reach the top risk bracket, the study found.

Residents were steadily more likely to refer patients to outside care as the patient’s risk score increased, but more experienced faculty members reduced their referral rates once patients reached the highest level of complexity.

“Multiple explanations may contribute to this change in referral rate across the continuum of utilization risk,” the authors posited. “First, faculty physicians may exhibit more comfort with patients at high risk of utilization. This comfort may decrease their tendency to order specialty referrals, ancillary services, or high-cost imaging procedures.

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“Next, patients in the faculty clinic—as a result of longer-term continuity and ongoing therapeutic relationships—already receive specialty care for their conditions, which may limit the number of new referrals originated during the study period.”

Overall, residents placed an average of 1.9 referrals per patient compared to faculty rates of 1.5 referrals per individual, which validates previous findings that providers with less experience generally rely on specialists to supplement their decision-making and patient care.

“Value may also play a role in the decision to refer patients at highest risk of utilization,” the authors noted “Faculty may make a conscious effort to improve the quality-to-cost quotient by requesting specialty consultation and high-cost testing less often for patients with a higher propensity to utilize healthcare resources.”

In general, providers in the patient-centered medical home environment and elsewhere should use referrals more judiciously to benefit the patient experience, avoid unnecessary confusion, and maximize resources, the article concluded.

“At this point, the ideal number of referrals is not clear. If healthcare systems continue efforts to improve care coordination and multi-specialty system integration, the risks of increased cost and care fragmentation may lessen.”

“Referrals’ contribution to quality, safety, and meaningful clinical outcomes requires further assessment. Health services researchers will need to address the utility of referrals in the setting of need for individual patients, providers, and healthcare systems.”

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