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Why PCPs Don't Always Refer to Your Preferred Specialist

Specialty care costs are high—and growing. Physician compensation is 46% higher for specialists than for PCPs, and specialist visits increased by 14% from 2012 to 2016 (while PCP office visits declined by 18%). Much of this spending is inadvertently at the discretion of the PCPs making referrals, with many missed opportunities to improve efficiency while maintaining high-quality patient care:

  • Unnecessary referrals for conditions that can be managed in primary care
  • Out-of-network referrals from a member’s specific product coverage
  • Referrals to low-value (high-cost and low-quality) specialists

Plans currently try to share information with PCPs on high-value referral patterns through network design, provider directories, and online provider portals, but there is still a lot of medical spend wasted on inappropriate specialty referrals.



1 The midpoint annual cost to the US health care system in 2011 from inappropriate pricing discrepancies.

Influencing specialty referrals from within the PCP’s office is perpetually difficult for plans, because they must work against entrenched clinician beliefs and habits when sharing specialist cost and quality information.

    1. Even the first steps are hard—specialists are often not open to plans sharing their individual quality data with PCPs. Specialists understand if a patient chooses a particular specialist for higher quality, greater convenience, or lower out-of-pocket cost. But specialists feel threatened when planstry to break historic referral patterns based on data they perceive as inaccurate—so plans fear upsetting the specialists and losing them from the network. Specialists don’t trust plans’ quality designations because they believe the data source is inaccurate, the metrics used are inappropriate, or that their patient mix is different from other specialists’panels.

    2. PCPs don’t believe that they will benefit from choosing a plan-preferred referral. Plans can appeal to members by highlighting the attractive qualities of their specialist recommendations—low cost-sharing amounts, convenient access, and high-quality scores, for example. But because PCPs aren’t specifically incentivized for making plan-preferred referrals, there’s no clear rationale for why they should change their referral patterns. PCPs also don’t see the patient benefit of choosing a plan-preferred specialist because they rarely receive information back from the specialist (or patient) to let them know if the patient ultimately had a high-quality, low-cost experience.

    3. PCPs offices already have engrained referral pathways. When members choose a specialist, it is often their first time and they’re looking for help (although not necessarily from the plan). When PCP office staff refer to a specialist, they typically have standardized pathways and familiar relationships to ease their busy days. PCP office staff benefit from these referrals because they already know how to contact the specialist (especially if they’re in their EMR), whether the specialist will give patient information back to them, and if the specialist has historically had appointments available for their patients.

Despite this difficult landscape, some plans have started to work around these challenges and make headway into guiding referrals from the PCP’s office. For example, one way plans can share information with PCPs on plan-preferred referrals is to explicitly incorporate PCP expertise into plan recommendations. To get started, our Specialty Referral Management Toolkit outlines how plans have done this and how you can apply the tactics to your own organization.

Berwick DM, Hackbarth AD, Eliminating Waste in US Health Care. JAMA. 2012; 307(14):1513–1516
Kaul S, et al., “Physician Response to Patient Request for Unnecessary Care,” The American Journal of Managed Care, Nov 2015,

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