How EHR-integrated referral management practices can lower specialty care costs

One of the imperatives for success in the rapidly evolving move to value-based care and eventual risk is the successful management of referrals. A coherent referral management strategy can help lower costs by emphasizing the value of referrals, which alleviates one of the concerns providers may have about their eventual move to a value-focused care model.

In a HIMSS20 digital presentation, Mark Foulke, executive vice president, transformational value-based care at Privia Health, highlighted the efforts Privia is making in helping providers better manage their referrals, regardless of their starting point on the road to value-based care.

Privia operates the Mid-Atlantic Accountable Care Organization, an independent physician network encompassing 1,100-plus providers, about 70% of them in primary care and the remaining 30% practicing as specialists. Combined, these providers tend to roughly 590,000 patients.

The first step toward achieving better referral management, said Foulke, is to engage physicians in a shared vision.

"You have to have a payer you're working with who understands the value you bring to the table, and they help align values from that," he said.

One way that this engagement can be fostered is by integrating referral management into physicians' existing workflows. By building the process into the electronic health record, it becomes a natural component of their day-to-day work, and removes the need for them to toggle into and out of disparate programs – which can hinder their focus and attention.

According to Foulke, Privia's approach works because physicians essentially run the show themselves.

"The reason the program works is physician-to-physician governance," he said. "When it's a white-coat-to-white-coat discussion, it brings more credibility. We created a system to have more physician interaction and governance. You can apply that logic to your own situation. … Physicians choose who the referral patterns are going to go to, and that creates buy-in."

What Privia did was create a cost-efficient, high-quality subset of preferred physicians and facilities across all payers. This has improved both the patient and provider experience, and created success in value-based care arrangements while also creating value for payers and specialists.

The way it works is that physicians select preferred specialists; the specialists and facilities are tiered in the EHR; and the preferred providers are evaluated, and high performers identified. The resulting preferred provider group includes only the highest quality, cost-efficient providers. That in turn leads to lower specialty care costs.

To illustrate the efficacy of the approach, Foulke pointed to one geographic region in which Privia operates that narrowed the referral network down to five specialties: cardiovascular, gastroenterology, ophthalmology, dermatology and orthopedics. The goal was to change historic referral patterns.

In 2016, 30% of referrals in the region were going to focused specialists. By 2019, that number ticked up to almost 62%.That was due in part to narrowing down the number of specialists in order to foster a more focused referral pattern. When they get more referrals, said Foulke, that creates incentives to work collaboratively on the value-based care side of the equation. In all, there was a 23% increase in preferred specialist referrals.

When primary care providers decide which specialists to develop relationships with, that drives referrals, said Foulke.

"Physicians can be creatures of habit," he said. "If there's a change, we have to provide them with ongoing information. Many times they might refer out-of-network on purpose if there's a medical need for that, but otherwise, providing information back to the providers can change those patterns.

"We fully believe in the value of physician-to-physician interaction," he said. "We believe in how important physicians are to our lives."

Twitter: @JELagasse

Email the writer: jeff.lagasse@himssmedia.com