Designing and managing specialist referral systems


Designing and managing specialist referral systems

In recent years, opportunities have expanded to provide primary care in outpatient settings, whether in freestanding clinics or embedded in other facilities such as pharmacies. CVS Health, Walgreens, Humana, One Medical, and others now operate hundreds of primary care clinics in the United States.1 Independent practices, freestanding urgent care centers associated with hospitals and health care systems, and community clinics operated by cities and counties offer primary care in accessible settings as well. 

All such providers must develop protocols for managing referrals to specialists. In geographical areas where primary care physicians (PCPs) know the specialists in their community personally, or where the presence of academic medical centers raises the standards of practice for other clinicians within their sphere of influence, it has been relatively easy to get a referral to a trustworthy specialist. Good and well-connected doctors tend to know who the quality specialists are, and refer to them accordingly. 

This informal arrangement has flaws, obviously; for example, physicians sometimes refer patients to their friends out of social loyalty, particularly if they aren’t aware of any significant differences in care quality between them and others in their field. There’s nothing unethical about this, but it does reflect the difficulty PCPs face in sorting hearsay from verifiable measures when it comes to specialists’ practices. And as primary care moves more to an independent, convenience-based clinic approach as indicated by the growth of players such as those listed above, those personal relationships will necessarily decrease in relevance. As such, then, providers and insurers need to develop methodologies that optimize the referral process for quality, cost, and appropriateness of care.

Well-Being and Cost

Patients can follow sensible steps to identify a specialist, including consulting with their PCP regarding what kind is needed (e.g., general vs. interventional cardiology), identifying personal preferences (gender, languages spoken), background checks (are they board certified?), ease of access (can they see you next week, or will it be four months?), and politeness of office staff.2

That said, however, patients face the same basic conundrum as PCPs and insurers; namely, beyond these basic considerations, how do you assess how good the specialist really is? Will you be entrusting your well-being to a clinician who’s merely affable or someone who’s also excellent in their field? It’s not unusual to hear stories from within medical centers about genial, well-liked surgeons who are actually the most dangerous to their patients—or by contrast, testy, unpopular ones who are nevertheless the most skilled and save a lot of lives. 

Finding the right specialist may contribute significantly to a patient’s well-being, of course, but these choices may also affect overall cost of care. In 2015, Atul Gawande, MD, published an article in the New Yorker delineating the many ways in which American health care suffers from excessive expense while simultaneously harming patients, due to the overuse of tests, drugs, and surgical procedures.3 For example, in a given year, 25–42% of Medicare patients had received at least one of 26 tests and treatments determined to be useless or even potentially harmful. 

Of course, it isn’t enough just to eliminate unnecessary care; it has to be replaced with necessary and appropriate care. One reason for inappropriate care, Gawande noted, is the asymmetry in knowledge between doctors (who typically understand the value of a given medical test or treatment) and patients (who often don’t, and must trust their physician’s judgment). This same asymmetry may exist to a lesser extent between PCPs and specialists, which can make referral decisions challenging.

Referral Decision Support and APS

What all stakeholders need, then—whether patients, payers, or PCPs—is referral decision support. This support will ideally provide the means to quickly identify the specialists in a given area who provide the best care as judged by cost, quality, and appropriateness. 

To provide that support, Motive Practicing Wisely Solutions has developed Appropriate Practice Scores (APS) that incorporate aggregated data from databases covering more than a billion physician–patient encounters. The analyzed results are summarized in a simple 0–10 rating—that is, the APS. An APS of 5 indicates average performance; higher scores are better, lower scores worse. 

The APS is bracketed by a range of better practice (ROBP), which accounts for factors not easily captured in claims data. These may include a variety of subtle clinical factors that affect care decisions, including the patient’s symptoms as well as personal or family medical histories. It may also allow for the clinical resources available to a given practice, geographic considerations, and issues related to referral.

APS relies on quantitative metadata such as costs from claims and fee schedules; strong statistical testing; and validated evidence. It is adjudicated by a 600-member network of subject matter experts, whose judgment is informed by Practicing Wisely’s ROBP methodology. This approach honors clinicians’ concerns by acknowledging that the real world of clinical practice comprises far more variations than absolutes. But it also emphasizes the importance of knowing what constitutes appropriate care in any given circumstances, and achieving it whenever possible.

The APS, then, is an extremely useful tool in determining the best specialists for referral. It allows payers or PCPs to compare physicians using a single score rather than multiple measures. And that single score incorporates a sophisticated weighting system that includes information about factors that are relatively more costly or potentially harmful. 


Payers that use the Motive Practicing Wisely APS have seen significant returns on investment (ROI). In one case, for example, a health plan needed to maximize ROI while meeting Centers for Medicare & Medicaid Services requirements for steerage of members to high-value providers. The plan integrated APS with its existing provider performance evaluation program to offer both direct member steerage and referral decision support for PCPs. Overall, the plan realized average savings of more than $100 per member per year by redirecting patients from lower-value providers to higher-value ones and developing a preferred referral list for plan PCPs, using APS and cost data for clear cutoffs.

Going forward, an increasingly decentralized primary care environment will increase the need for decision support in specialist referrals. The Motive Practicing Wisely appropriateness of care measures and the APS offer patients, practitioners, and payers the information they need to make the best and most cost-effective decisions in one easy step.


1. Lee J. Health Insurers and Retail Pharmacies Are Making a Play for Primary Care.

2. Howley E. How to Choose the Best Specialist Doctor.

3. Gawande A. Overkill. New Yorker, May 4, 2015.