By Matthew DeCamp, MD, PhD


The last time you visited your primary care physician (PCP) and received a referral to a specialist, how did you choose the specialist you ended up seeing? Perhaps you stayed within the same hospital or health system, chose to go to one close to your home, or found the one who could see you the soonest. Perhaps you chose the one whose copayment was lower, based upon your health insurers’ preferred network. Or perhaps you asked your PCP whom he or she thought was best for you, and saw that person.


Given these different considerations, it may be obvious – but still worth mentioning – that your choice was not completely “free”. You and your PCP no doubt thought the choice was best for you, but your choice may have been influenced by cost, convenience, and probably a number of other factors.


And yet when health care organizations start proposing ways to exert new influences over this process, we quickly become uncomfortable about this seeming intrusion on our choice. This reaction may be well-founded, given the tattered history of managed care (where physicians were sometimes under financial pressures not to refer, to refer only within the organization, and so on – practices many considered unethical).


But that doesn’t make all influences unethical. In a recent New England Journal of Medicine article, Lisa S. Lehmann and I provide a roadmap for how health care organizations can influence referrals in ways that respect choice and protect patient well-being.


Why are health care organizations interested in influencing referrals?


The short answer is the increasing push to provide high value care – care that is both high in quality and lower in cost. Many of the recent health care reforms are shifting financial risk to organizations that provide care; instead of being paid on volume, organizations are increasingly being paid on value. At the same time, evidence suggests that existing referral practices may not promote this type of high value care.


Our focus is on accountable care organizations (ACOs), which continue to proliferate within Medicare and private insurers, but our recommendations apply to any organization or system interested in influencing referrals. (For background on ACOs, see prior posts.) ACO arrangements vary, but the core idea remains: Many ACOs, such as those in the Medicare program, are responsible for ALL of a patient’s costs – whether inside or outside the ACO.  This creates an obvious interest in where patients receive care. So it is not surprising that ACOs are exploring ways (such as lower copayments for patients or preferred referral status for physicians) to encourage care within the ACO or from physicians preferred for quality and cost reasons.


A New & Improved Referral Process?


Leaving the article’s details for you to read, imagine a different version of scenario above. Having decided a referral to a specialist is needed, you and your PCP next review the organization’s list of high value providers. The list includes a description of the organization’s goals as applied to referral processes, such as a desire to provider better coordinated, higher value care, at lower cost. It also openly describes the factors that went into its creation, including not just how specialists perform on purely medical outcomes but also factors of interest to you (such as scheduling convenience, proximity, racial or gender concordance, or others). Together, you choose a specialist from that list (recognizing your shared interest in high value care); or, if you don’t, you decide upon a different specialist best for you (and do so at the same low co-payment, through a special appeal to the organization).


Some might say that this version of the scenario was not only ethically permitted, but also an improvement over the status quo: This choice arguably was both better informed and more consistent with the patient’s overall interests. As a PCP, I might welcome having this kind of information on hand for my patients.


What do you think?



Matthew DeCamp, MD, PhD, is an Assistant Professor at the Johns Hopkins Berman Institute of Bioethics and in the Johns Hopkins Division of General Internal Medicine.  A practicing internist, his current research interests include social media and medical professionalism, ethical issues in health reform (focusing on accountable care organizations), and global health (with special emphasis on short-term global health training).

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Matthew DeCamp

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