How many physicians know how many visits they are approving when referring to a specialist?
This was a germane question posed to me today. I first asked this question of myself as a junior faculty member, while busting the residents’ chops over the egregious numbers of referral visits they were approving. You see, as any good resident knows, being proactive in the referral department demonstrates skill in the art of “avoiding being bothered with repeated requests for *#%!. This is a skill that one either develops or does not, the latter being associated with career-long anguish. However, in my residency program (circa 1997), I was immersed in the wonderful world of managed care, teaching residents the difference between an HMO and a PPO, a heart attack and an acute case of thoracic shingles, a referral with too many visits and one with not enough. Too many = bad. Not enough = good work!
Many of these lessons evaporated with the volcanic changes that supplanted most HMOs with PPOs. Meaning that we went from gatekeepers to zookeepers (or maybe free-range doctors). The incentives to address the referral process gradually dissipated, and with it, the very term “referral” came to mean many things to many people. In fact, you can get a great metaphysical conversation going at a party (of geeky, middle-aged internists) with the question, “What is a referral?” The point is, it is probably going to start mattering again because risk contracts are back in vogue. Skin is in the game.
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