Keep referral relationships on track

A column about keeping your practice in good health

By Mike Norbutcovered practice management issues during 2002-06. Posted Jan. 30, 2006.

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Referring patients to a specialist can get to be a pretty routine task for most primary care physicians. Doctors usually have set referral patterns that become less likely to change as time goes on, and specialists generally get comfortable once they have established a healthy stream of referral sources.

But what happens when a specialist is retiring, cutting back on patients or dropping a patient service? Without adequate communication, referring physicians may be left apologizing to angry patients and trying to find a new specialist on short notice.

Instead, primary care physicians who keep track of their referral patterns and specialists who keep their colleagues apprised of their practice situation will be able to keep business flowing smoothly, health care consultants said. Primary care physicians should check with specialists from time to time to ensure that they haven't dropped certain services or had a physician leave, while specialists should inform primary care physicians whenever any changes affecting patient care are going to happen.

While correspondence between specialists and referring physicians is common practice, it usually occurs only after a patient has been referred. The letter addresses the patient visit and not the service changes the specialist is planning, consultants said.

If the doctors have not discussed those changes, the primary care physician just assumes things are status quo when he or she makes a patient referral.

"The only way a doctor will find out is from the patient after he makes the initial referral," said Bob Erra, president of Management Science Associates in Kansas City, Mo., a division of Clark Consulting. "Once that happens, they have to contact the office and find out the circumstances."

While it may take only one angry patient to change a referral pattern, that one misplaced recommendation could cause a flurry of administrative hassles, as you try to find a suitable replacement specialist on short notice. The patient also could be angry enough to seek out a new primary care physician.

Insurance network limitations make the referral process even more difficult, said John K. Frederick, MD, a family physician in Austin, Texas. His four-physician practice, South Austin Family Practice Clinic, keeps a list of specialists the doctors are familiar with, but he has to cross-check that list against insurance panels to choose one who contracts with the patient's insurance company.

"I still know the ones I use very well," Dr. Frederick said. "But ones in high-demand fields, like dermatology, a lot of times don't participate in any plan. I give patients the name of one around the corner, but more likely they'll see someone I don't use."

Insurance limitations can increase the chances you might refer a patient to an unfamiliar specialist, which in turn increases the risk that you can send patients to a specialist who might not be able to help them.

"For the most part, specialists are good at communicating with me to keep me happy, but it can be difficult when a patient goes from one doctor to the next because of insurance," Dr. Frederick said.

Dr. Frederick said he also has experienced situations where he referred a patient for one condition, but the specialist "usurped" treatment for other conditions as well.

For example, a primary care physician refers a patient to a cardiologist to check for or treat coronary artery disease, but the specialist also starts to treat the patient's cholesterol level as well, he said. The specialist naturally is qualified to address that issue, but that's not the reason the patient was referred, he said.

While primary care physicians should check up with specialists from time to time to make sure their services haven't changed, consultants said the onus largely rests with the specialists to get the word out when changes are afoot in their practices.

If a specialist wants to funnel patients to a new physician in the practice, for example, he or she should take the time to introduce the doctor to referring physicians in the community, said John Wells, a health care consultant in Columbus, Ohio. If the practice has a long-standing relationship with the specialty group, it likely will give the new physician the benefit of the doubt, Wells said.

Meanwhile, if a physician in a smaller practice is retiring or cutting back on services, he or she should write a letter to referring doctors offering suggestions for who could see those patients, consultants said. That could be a dangerous road to travel for a specialist, however, because if primary care physicians change their referral patterns, it's difficult to alter them again later, Wells said.

"To start that faucet back up is hard," he said. "Once you've made that decision, it's usually final."

Those ob-gyns who might have stopped delivering babies because of medical liability insurance costs could get a chance to test that if rates drop to a more affordable level. Larry Veltman, MD, an ob-gyn in Portland, Ore. and chair of the American College of Obstetricians and Gynecologists' Committee on Professional Liability, said that, according to the organization's last survey, 9% of those responding reported that they had given up obstetrics because of liability premium costs.

While many of those also were probably tired of the unpredictable and hectic schedule, a few could decide to deliver babies again in the future, he said. "If a physician wanted to do that, it would behoove them to sit down over lunch or have a face-to-face meeting with a referring physician and say, 'I'm back in the game,' " Dr. Veltman said.

Mike Norbut covered practice management issues during 2002-06.

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