Managing Referrals in an Accountable Care System

Written by on August 30, 2013 in Features - No comments

In the United States, about 66 million people live in rural areas or urban neighborhoods with too few primary care doctors or a shortage of primary care in clinics. Estimates indicate that 1 in 5 Americans lacks access to essential primary care and could develop more serious health problems as a result.  Access to specialty care is equally challenging in these communities.

Value based, population focused models of care delivery rely on proactive identification and management of the “highest risk” patients.  These “sickest of the sick” patients need to be accurately attributed to physicians and care teams in order for these care teams to coordinate care across the entire continuum and systematically manage multiple chronic illnesses through use of a common care plan.  This is the definition of true clinical integration and is a challenge in our current system.

Referral management in such a system becomes increasingly important as we work to meet the triple aim goals of delivering the highest quality care at the most efficient cost with great patient satisfaction.  The concepts of accountable care and shared savings imply a coordination of information that enables this success.  Coordination and delivery of timely information are the greatest challenges in making the data “actionable” for providers and patients.

Some estimate that Accountable Care Organizations could be responsible for managing the 40% of all office visits that are referrals from primary care to specialty practitioners.  Referral systems ideally would include clinical guidelines to ensure that all “pre-work” and screening is done in the primary care setting prior to specialty referral when the care required for the patient exceeds the availability in the primary care office.

Referral management systems must include reciprocal communication from primary care to the specialist, detailing the needs and clinical data for the patient, and back from the specialist to primary care, detailing the results of consultation and treatment.

Coordination and communication regarding clinical outcomes will be critical to payment in the value based world.  Future shared savings models will distribute funds based on adherence to clinical guidelines and provider payments may be based on this adherence as well as meeting or exceeding quality targets.  Meeting the goals of clinical integration will involve coordination and cooperation between specialists and primary care in a new paradigm.


By Lisa P. Shock, MHS, PA-C
President/CEO Utilization Solutions in Healthcare, Inc.


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