That conflict illustrates a common problem throughout the healthcare industry. Physicians often do not have the data they need to best use their referral network, according to a new survey from Kyruus.
They tend to refer their patients to a small network of favorites who they know and trust. While this may boost patient retention, doctors typically don't have the most recent data on if those physicians changed hospitals or may be out of network. This may leave patients with surprise bills. It could also put them in a tough spot if providers don't recommend more than one doctor.
Nearly three-quarters of the 200 primary-care physicians and specialists surveyed said that for a given specialty, they or their office staff usually refer patients to the same provider. This implies that there could be missed opportunities to connect the patient with a similar physician who can see them sooner.
Also, 62% of doctors said either they or their staff referred the patients to a specific provider, while only 28% recommended several providers.
This behavior stems from a lack of awareness of in-network options and the clinical expertise of current colleagues, according to the survey.
"We create these micro-networks who are safe and reliable, yet that can be a real disservice to our patients if we don't factor in if the provider has the optimal insurance coverage, if they are in an optimal location and if they have the optimal language capabilities that our patients need," Jospe said.
Many health systems have acquired physicians to expand their referral network and care for more patients. But that strategy has been a risky one, as some systems have grown too fast and lost control of their networks.
"They buy up a bunch of practices and then find out that 60% of their specialty referrals are going to a competing hospital—then they are cooked," said Jimmy Burnett, a managing director at Navigant Consulting. "There is a big opportunity for healthcare systems to improve their bottom line on physicians by really understanding their network, who is loyal to them and where the leakage is."
Only 60% of primary-care physicians and specialists surveyed have access to a provider directory curated by their health system.
A wider network can also be an asset, if used properly, as providers can better match patients with physicians, Jospe said.
While 77% of providers surveyed recognize the importance of keeping patients in-network for care coordination, 79% say they refer patients out of network. One-third of out-of-network referrals would be avoidable if they had access to more information about providers in their networks, the survey noted.
"One of the core issues is the provider directory—just knowing what doctors are in a market, what type of provider they are, where they are located, what insurance they accept," said Marc Lachs, vice president at Optum. "That is something we see individual practices and large health systems really struggle with."
Only 58% of providers feel they are practicing at the top of their license all or most of the time, suggesting that physician satisfaction could improve with better patient-provider matching during the referral process.
Physician satisfaction is an increasingly important metric as burnout rates increase and health systems struggle to retain and recruit clinicians. If doctors don't have access to the information they need, it will add to their stress.
Patient experience is also a critical part of the healthcare system. If they are unhappy after receiving a surprise bill or have to wait weeks or months for an appointment, patient safety and outcomes could be jeopardized.
"It's important to ensure that there is a closed loop for these transitions and understand the patient-safety ramifications of not doing this well," Jospe said.
When making a referral, 64% of surveyed providers think it is extremely or very important to schedule an appointment before the patient leaves the office.
However, providers estimate that only 4 in 10 patients leave their office with an appointment scheduled for their referral—a gap in the process that can lead to patients ending up with providers outside of the system or not following up at all.
Democratizing the data, making it digestible and getting it in the right hands would help, Jospe said. There needs to be greater democratization of the workflow—the onus shouldn't fall on one person who doesn't have the capacity or nuanced understanding, she said.
Consolidation can contribute to this data void. Systems have struggled to aggregate pertinent data related to health records, billing and care quality, let alone making it actionable.
Financial incentives can also influence referral patterns. Employed physicians are more likely to recommend unnecessary treatments if they are used as a vehicle to pay what are effectively kickbacks for referrals, according to a 2014 study published in Health Affairs.
To change the dynamic, providers need to share insurance, quality, location and specialization data of the peers in their network, according to the Kyruus survey.
"There needs to be some means of enabling a culture shift," Jospe said.
Health systems also need to streamline the ability to schedule appointments before patients leave the office, possibly by including referrals and scheduling in one platform, experts said.
"There is a lot at stake," Burnett said.