AdvantageCare Physicians (ACP) is a multispecialty practice that provides specialty and general medical care to patients in the New York City and Long Island area. The cost of sending patients to out-of-group (OOG) facilities can be extensive to a multispecialty group. Each patient that is referred out of group can cost more than $3,000.
ACP conducted a pilot study at the Valley Stream and Hempstead offices in Long Island, N.Y., from August to October 2015 to identify the reduction of OOG referrals as a cost-saving measure.
The study was conducted with the cardiology and primary care departments at both facilities. First, we identified the most common causes of OOG cardiology referrals: pacemaker interrogations, abnormal EKG, chest pain, chronic disease management, high blood pressure and high cholesterol treatment, and urgent cardiac clearance for surgery.
These common cardiology pathology management algorithms (“pathways”) were created with management and referral criteria and presented to the primary care staff at a department meeting. The staff received two pathways for what we called curbside consults: an inter-staff message option in the EPIC EHR and a direct contact number to reach specialists within 24 to 48 hours. This would allow for quicker feedback and quicker management decisions as well as improved communication with specialists and less need for inappropriate referrals.
We monitored OOG referrals for three months at both facilities and tabulated results to identify change in referral practices.
Results
The Hempstead clinic reduced OOG referrals during the study: from 15 in August to eight in September and 11 in October. The clinic also significantly used staff messages and curbside consults.
The Valley Stream office showed an increase in OOG referrals: 16 in August to 17 in September and 20 in October. Valley Stream also used the staff message resource and curbside consult less frequently.
While it is difficult to measure the difference between Hempstead and Valley Stream as contact was provided via phone and staff messaging consultation as a confounder, there was more utilization of the contact number in the Hempstead office versus the Valley Stream office for curbside consult with the specialists. Furthermore, 25 staff messages with medical questions regarding patient care referrals and management were sent to specialists from Hempstead compared with seven from the Valley Stream office.
We measured the proportion of OOG referrals to the number of total consults and then calculated the absolute percentage change.
The Hempstead office had a significant absolute 12% reduction in OOG referrals (Table 1.)
The number of total consults fluctuated at both sites, and the proportional change of OOG to total referrals was assessed (Table 2). A relative reduction of 2% occurred at both sites, which can be explained by the increased utilization of the medical specialist for curbside consults in the Hempstead compared with the Valley Stream office. Assuming 218 patients at Hempstead and 480 patients at Valley Stream with a $3,000 savings per patient, this would reflect a savings of $13,000 at Hempstead and $28,800 at Valley Stream. This reduction was noted in the settings of asynchronous messaging through the EHR to reduce OOG referrals. Education was likely the major factor in reducing OOG referrals. Monthly physician meetings, pathway education and education regarding appropriate testing before making a referral were provided to both sites.
There is a difference in the number of primary care physicians (PCPs) and cardiology referrals at both sites, which may have been a confounding variable in this study. Hempstead has four doctors and Valley Stream has five doctors and one nurse practitioner. In the future, there might be a role for recurring education for PCPs with specific disease management algorithms or pathways as this was positively received by primary care staff. Increased use of specialist curbside consults among PCPs resulted in more standardized management of common cardiac problems, including hypertension, chest pain, shortness of breath, myocardial infarction and atrial fibrillation.
The timeliness of feedback (24 to 48 hours) from the specialists was also a key component for successful specialist utilization. A formal route of communication to specialists could reduce referrals in the event of management questions. This could mean providing a specific portal communication system to provide inter-provider curbside consultation via a secure mobile application like TigerText or EHR.
OOG referrals can be a significant loss of revenue for large multidisciplinary practices that function as ACOs. Patients staying within an ACO provide other noneconomic benefits, such as continuity of care and seamless communication with providers. This study suggests potential opportunities for improving OOG referral rates through primary care education and formalized routes of communication.
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