“The best hand surgeon to repair my very complicated tendon situation works at the hospital across the street,” a guest lecturer quoted her patient, “George,” as saying. “We both knew this,” she explained to the audience at the Massachusetts Medical Society lecture series. “Why, George asked me, aren’t you referring me to “Dr. Fantastic”?”
“So I referred him, of course–but I was a bit nervous about the reaction from my colleagues in our hospital-owned practice. We had been strongly encouraged to only refer in-house.”
The reaction from her colleagues was immediate and overwhelmingly negative, the young physician said. Both the practice and the young doctor suffered financial repercussions. And she was certainly not commended for referring her patient to the best physician for a very complicated case that would have an excellent outcome thanks to the specialist’s great skill and knowledge.
According to a 2018 poll by Medscape, a physician education website, the vast majority — 84% — of physicians stated that their health system had requirements for referring to in-network providers, and most (79%) of those physicians agreed with the mandate. But when Medscape asked whether physicians would refer patients outside of their health system despite pressure to refer patients within, 86% said yes.[1]
However, only the medical centers themselves know how well physicians are resisting the pressure to refer in-house.
At some hospitals and health systems, those financial and psychological pressures are tremendous: physicians are expected to refer only within the system even if the physician believes the patient will receive better care from an outside specialist.
At Seward Medical center in Boston, for example, The Boston Globe interviewed physicians who described a culture where their colleagues were shamed by having their names displayed on a screen with the number of their patients who had been referred to other medical centers for care. [2] Dr. Claudia Gabrielle quit Seward to work for a Beth Israel Deaconess Medical Center practice that does not place such negative incentives on doctors: Seward, she said, “became very money driven,’’ she was quoted as saying by the Globe staff reporter.[2]
Ignorance can Lead to Bad Patient Outcomes
Patients are hurt by these pressures in three ways.
First, patients may falsely believe that their physician is acting solely in the patient’s best interest — not knowing that their physician may be incentivized to refer within their medical system and thus potentially consign their patients to inferior care.
For example, when their daughter “Julie” was diagnosed with new onset Type 1 diabetes at age 6, her parents, “Ron and Jacquie” were told to take her to a major medical center, but not to the children’s hospital in their town. The care was lackadaisical at best: the physician they were referred to specialized in testosterone disorders; it quickly became apparent that he didn’t know much about diabetes medications. The patient educator, although very personable, shared that he had just left a job in shoe sales and had started working at the diabetes clinic only a few days before. “Do you have any literature about Type 1 diabetes?” he was asked. “I don’t know,” he hesitated; then added, “Look, there’s a book up on that top shelf!” He handed down the large volume to the patient’s parents as if it were a shoe box.
When the parents shared the story with the child’s pediatrician, he admitted that he had been strongly encouraged by the hospital in which his practice was located to refer patients only to that center. On hearing of the parents’ experience, the pediatrician immediately made a second referral to the local children’s hospital, where the child was treated by an excellent and knowledgeable pediatric diabetes specialist and an experienced support team. But there were consequences: good care for their daughter had been delayed and the onus of needing to seek out better care at that difficult time was exhausting to both the patient and her family.
Bureaucracy as a Way to Discourage Referrals
A second problem can arise when a patient does exercise his or her individual preference to seek a specialist outside the network of the primary care doctor and becomes the recipient of subtle (or not so subtle) retaliation.
Mike, a client I advocate for, decided to receive a transplant at “Mercy” Hospital rather than “St. Regis”’ where “Dr. Dave,” his primary care doctor practiced, because his nephrologist was associated with Mercy. Dr. Dave told him that he would no longer write referrals for him to Mercy. It was not a matter of insurance coverage–his insurance would pay at either facility. His PCP just felt overburdened, he said, by the referrals. As a result, Mike received a very high insurance bill for a few visits the PCP had neglected to write referrals for, because he had sought care “without a referral.”
Dr. Dave eventually relented and wrote the referrals when I reassured him that Mike would be seeking a new PCP who worked in the same medical system as the transplant center.
You Must Request an Outside Referral
The third way patients are potentially harmed by this system is that they may not know that they may need to formally request a referral to an outside specialist.
It is important for patients to know that most doctors’ contracts permit the physician to refer outside their own medical center if a patient requests it or if it’s in the patient’s best interest; but first–a patient has to know that they can request such a referral.
It used to be that a primary care physician (PCP) was an important source of referrals to other excellent physicians in the community. But some PCPs are not necessarily fulfilling that role because they may be strongly encouraged to refer patients only to the medical center the physician is affiliated with.
For example, when “Brad” required a referral to hospice, the patient’s family reached out to the PCP for the required referral. The PCP said “by the way, we refer to “Unified” hospice.” The patient’s family shared that they wished for a different hospice that their social worker had told them was well regarded in the community. The physician immediately agreed to write the referral–but it helped that the family knew that they could request an outside referral.
The Backlash
Some doctors are fighting back–or leaving systems that are too controlling.
Last year, Dr. Stephen Zappala, a Boston urologist, sued the Seward medical system; the Boston Globe reported that Dr. Zappala turned a bright light on a system where “company representatives exerted immense personal and financial pressure on him and other physicians to refer patients only to Seward hospitals and specialists, putting profits first.”[2]
The same attempt to pressure physicians occurs when there is a choice of places to perform procedures or tests. In another case in Boston, a surgeon, Dr. “Kroeger,” was criticized by the CEO of an area hospital where he had privileges. “Why are you performing more surgeries at “St. Joseph’s” hospital than here?” he was asked. He was told he needed to meet personally with the CEO of the hospital to explain his choices. He had privileges at both, he said, but the nursing support staff was better at the hospital he preferred–he felt there were better patient outcomes there, he said.
Dr. Kroeger worried that he might end up sacrificing not only his personal preference and autonomy to choose but the health of his patients also.
How to Find the Best Specialist
How can patients find specialists if they have highly complex cases that require a very skilled physician and wonder whether the specialist to whom they have been referred is the best one for their condition? Word of mouth is not always enough and the internet does not offer much guidance. In these cases, it can be incredibly helpful to have a relative who works in the medical world, or a physician who is willing to buck the trend and refer outside the network, or a patient advocate who can do the research and suggest sub-specialists who are both highly regarded and covered by the patient’s insurance.
The commercialization of medicine has resulted in doctors potentially being penalized for referring their patients to the best specialists in a way that can erode the autonomy of the physician and the patient: the physician may be forced to refer in-house even if he feels it is the wrong thing to do and the patient who expresses a personal preference or does his homework and wishes to seek care from the best specialist may find his choice strongly discouraged.
When patients and physicians exercise their clinical judgement and their freedom of choice, they should not be penalized for it. But it is important for patients to know that they can access the care of excellent specialists outside of a given medical center if their insurance covers it — but they may need to advocate for themselves and request a referral and they may need to do so emphatically.
[1] Leigh Page. Is It Ethical to Pressure Physicians to Refer In-House? – Medscape – May 21, 2019.
[2]“Steward Health Care pressured doctors to restrict referrals outside chain, suit says” Liz Kowalczyk Boston Globe, MAY 24, 2018.
The names of the hospitals, patients and physicians in quotation marks have been changed to protect physician and patient confidentiality. The suggestions given here are not intended as a substitute for the medical advice of your physician.
Photo credit: photo by Isabela Kronemberger, from Unsplash.com
