Abstract
BackgroundReducing inappropriate referrals to specialists is a challenge for the healthcare system as it seeks to transition from volume to value-based healthcare. Given the projection of a severe shortage of rheumatologists in the near future, innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. Efforts to increase appropriate utilization through reductions in capacity may have the unintended consequence of reducing appropriate care as well. This highlights the challenges in increasing the appropriate use of high cost services as the health system transitions to value based care. The objective of this study was to analyze factors affecting appropriateness of rheumatology services.MethodsThis was a cross-sectional study of patients receiving Rheumatology services between November 2013 and October 2019. We used a proxy for “appropriateness”: whether or not there was any follow-up care after the first appointment. Results from regression analysis and physicians’ chart reviews were compared using an inter-rater reliability measure (kappa). Data was drawn from the EHR 2013–2019.ResultsWe found that inappropriate referrals increased 14.3% when a new rheumatologist was hired, which increased to 14.8% after wash-out period of 6 months; 15.7% after 12 months; 15.5% after 18 months and 16.7% after 18 months. Other factors influencing appropriateness of referrals included severity of disease, gender and insurance type, but not specialty of referring provider.ConclusionsGiven the projection of a severe shortage of rheumatologists in the near future, innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. Innovative strategies to decrease demand for rheumatology services may prove more fruitful than increasing the supply of rheumatologists. These findings may apply to other specialties as well. This study is relevant for health care systems that are implementing value-based payment models aimed at reducing inappropriate care.
Highlights
Reducing inappropriate referrals to specialists is a challenge for the healthcare system as it seeks to transition from volume to value-based healthcare
To understand whether induced demand for rheumatology care leads to an increase in inappropriate referrals, we looked at the effect of the start of an additional rheumatologist on the appropriateness of referrals
We looked at this effect 2 months after the start of the rheumatologist and during a washout period of 6 months, 12, 18 and 24 months, enabling us to analyze the referrals pattern over a period of time
Summary
Reducing inappropriate referrals to specialists is a challenge for the healthcare system as it seeks to transition from volume to value-based healthcare. Efforts to increase appropriate utilization through reductions in capacity may have the unintended consequence of reducing appropriate care as well. This highlights the challenges in increasing the appropriate use of high cost services as the health system transitions to value based care. Specialists are more expensive [2, 3], use more ancillary services [4], and often provide care outside their narrow provider specialty [5] Beyond those issues, the availability of many specialists is limited, with projections of shortages for many specialist types [6, 7]. As the healthcare system begins to transition away from volume and toward value based care [8,9,10,11,12], the financial incentives for the use of specialty care are transitioning [13,14,15], leading to a need for more effective targeting of patients to specialists
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