Specialist cost and quality: What do primary care physicians need to know?

March 4, 2019 / By Steve Delaronde

Primary care physicians (PCPs) want data that can be used to better serve their patients. If they can easily access timely and relevant data, they will use it. Cost, quality and care coordination are all important factors in helping physicians determine the best specialist referral for their patients.

PCPs are beginning to understand the cost implications of their decisions for their patients, as more patients face rising out-of-pocket costs like coinsurance, copays and higher deductibles. PCPs that have pay-for-performance and value-based care incentives are additionally incented to improve patient access to high quality and low-cost specialists.

The challenge is to get usable data into the hands of physicians. According to a 2018 survey of 624 primary care and specialty physicians, 14 percent responded that they receive quality information and only 6 percent receive cost information on the physicians and facilities to which they refer patients. However, 72 percent of physicians consider some type of cost-related information valuable at the point of care. Clearly there is a gap between what physicians want and what they get.

The more important question is whether physician behavior would change if they had cost and quality data. The same survey found that 60 percent of physicians that receive cost data for physicians and facilities to which they refer indicate that they have changed the way they practice because of this data, whereas only 23 percent of those that do not receive this information think it would change their behavior. Thus, the impact of data on physician behavior change may be greater than expected.

While value-based care programs may incent physicians to seek cost savings, keeping services within a hospital system is another goal for many PCPs that work within a specific hospital system. This means that high quality, low-cost specialists that work outside the system may not be prioritized. However, there is still an obligation for the PCP to make this information available to the patient, while highlighting the best performers within the system.  The opportunity for patient care coordination can also be greater when the PCP and specialist work within the same healthcare system.

The opportunity for PCPs to direct the care of their patients has multiple benefits, including lower costs, better outcomes and improved care coordination.  Increasingly, patients are bypassing the PCP when making their own specialist care decisions. While this may be appropriate in some cases, the long-term benefit of PCP involvement in helping patients with these decisions is clear, particularly to patients with chronic and complex conditions. PCPs can best fulfill their role by having the information they need to guide their patients to the most appropriate and highest quality care.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.