How healthcare reform changes referral patterns?

As a specialist, one of the saddest truisms about practicing medicine in the private world has always been how little one’s clinical skills determines referrals. Unfortunately, as our present healthcare climate pushes “providers” to consolidate along the lines of major hospital networks this injustice will only worsen.

A decade-or-so ago when I started private practice it was obvious that referrals came to me because of my association with an established group. This association was essential, as one could have been the next Michael Jordan of electrophysiology, but referrals would still have gone along historic lines, to the favored group. It would have taken a herculean effort, over years, to encroach upon such long established referral patterns–etched over the bonds of rituals like Wednesday afternoon golf matches and dinner clubs.

Thus, few specialists start independently. You join an established group, do good work, form relationships and eventually, your quality becomes known. As it should be: do good work and doctors will trust you with their patients. But yet, even the highest caliber specialists may fall prey to the easily accessible, affable, but (unknown and untested) new guy.  For enhancing referrals, availability and affability trumps skills—at least ninety percent of the time.

Now there is a new trump card for referrals: physician consolidation. Who owns who. For example, hospital X’s primary care doctors refer their cardiology (substitute any specialty) to hospital X’s cardiologist.  And so on with hospital Y and Z.  Like in this example, as one local oncologist bemoaned to me recently: “referring doctor Y used to refer me all his patients, but since the acquisition, he sends his mom and brother to me, but sends the rest of his patients to his new mother-ship’s oncologist.”

My message here is not to cry sour grapes, but rather to echo two themes.  First, to mirror the message of the WSJ’s recent editorial—although a goal of healthcare reform is to enhance competition, paradoxically, in the case of incentivizing provider consolidation, patients’ choices are diminished. You (the patient) will be seeing our cardiologist, or our surgeon, or you will be having your MRI at our (smaller, but less costly) scanner.

The other motive for highlighting these new allegiances is that patients should understand the mechanisms at hand in deciding which specialists they are recommended.  Isn’t it fair that a patient know that their doctor may have signed a contract agreeing to use the ‘company’ doctors? (Sure, there was a also a clause in that same contract saying the ‘company’ would not interfere with medical judgement, but we all know that persistent rogue referrals will likely result in an unpleasant fireside chat.)

In employing doctors, the primary master of the profit-driven health care corporation is physician productivity; CPT codes and workRVUs are the grading system, the language.   The code for an ICD implant is 33249 and its reimbursement is set, regardless of whether it is appropriate, or done right. Hopefully, the companies that employ the best doctors will find ways (besides profit) to distinguish themselves.

Providing higher quality care, to millions more, at lower costs will surely have its consequences. Undoubtedly, for patients one of these will be fewer choices.  When eating for free, only the most daring ask for a special order.

Be daring.

JMM