THE REFERRAL PROCESS

Reengineering Referrals to Improve Satisfaction

Effective utilization management minimizes inappropriate and unnecessary care. Traditionally, most plans have required prior authorization to specialists. The purpose has been to manage specialty care in a cost-effective fashion. But an overly rigid or cumbersome referral process annoys both members and practitioners. How can a plan maintain an effective referral process while ensuring satisfaction? This health plan, guided by feedback from its members and practitioners, reengineered its referral process.

Twice a year this health plan conducted a telephone survey of members to determine their satisfaction. Members were asked about a variety of areas, including hospitalization, emergency care, enrollment, access, claims payment, and the referral process. Members consistently indicated an unacceptably low level of satisfaction in these areas. Through an analysis of survey results, the plan identified the importance of the referral process to overall member satisfaction.

The plan's existing referral process required that all primary care physicians (PCPs) contact the health plan utilization management department to request and state the medical necessity for patient referral to a specialist. Once approval was received, the provider would notify the patient.

Because the member complained that this process was cumbersome and time consuming, the plan's staff decided to focus their initiative on increasing satisfaction with the referral process.

The targeted population included all members who had received a referral to specialty care. The measure used was the percentage of members indicating satisfaction with the referral process.

The plan used a semiannual telephone survey of a sample of its members (the sample size was originally 200 members but was increased to 385 in 1996 to enhance the statistical significance of the results). Members who responded with a "3" or "4" on a 4-point scale were classified as satisfied with the referral process.

Baseline data from the fourth quarter showed that 70% of surveyed members were satisfied with the referral process. Based on the average of all plans affiliated with its parent company, the plan established a benchmark and goal of 77%.

To manage the initiative, the plan established a satisfaction work group. The group began by developing a Referral Bypass Program in September 1994. This program allowed some PCPs to make referrals to participating specialists without obtaining authorization from the health plan. Participation was limited; PCP had to meet the following criteria:

• Serve a minimum of 50 members
• Have a contract with the health plan for at least one year
• Fulfill all contractual obligations
• Continue to accept new patients
• Receive no more than two member complaints during a rolling six-month period

Late in 1994 the plan published an article in its provider newsletter to explain the new referral program.

MULTIDISCIPLINARY TERMS In addition to sound and reliable data, this initiative depended a good deal on the plan's satisfaction work group. The work group members included representatives from the plan's marketing and sales, quality management, provider services, member services, claims, and research departments, as well as a medical director.

Results from the second quarter of 1995 showed a referral satisfaction rate of 72%, a change that was not statistically significant. The plan decided that its Referral Bypass Program affected too few providers to impact member satisfaction. The plan therefore decided to take a more comprehensive approach and began development of a new referral process, the Rapid Referral Program.

In the fourth quarter of 1995, the plan calculated a member satisfaction rate with the referral process of 74%, still not a statistically significant improvement. Results of data analysis confirmed a continued need to revise the referral process. As a solution, the plan implemented the Rapid Referral Program, which had been in development since the second quarter.

This new program involved 100% of the plan's PCPs. It allowed them to fax referral requests for entry into the utilization management database. In this system, the requests are entered into the database within 24 hours of receipt. When the requests are entered into the database, both the member and the specialist receive a confirmation. The plan's utilization management department sent a representative to the PCPs to education them on the new referral process. In addition, the new plan published an article in the member newsletter with information about the new Rapid Referral Program.

Survey results from the second quarter of 1996 showed a satisfaction rating of 80% within the referral process, a significant improvement over the baseline measurement.

Though the plan had exceeded its goal of 77%, survey results indicated a barrier to referral requests for repetitive specialty services. PCPs were annoyed at having to repeatedly request referrals that were needed on a regular basis. To solve the problem, plan policy was revised to allow PCPs to determine the number of encounters - for up to one year - that should be included in a referral for a selected repetitive specialty service such as allergy shots or physical therapy.

ROOT CAUSE ANALYSIS Repeated data analysis of the root causes for dissatisfaction was a key to implementing this initiative. The health plan staff began with good data on member satisfaction and then dug deeper to identify the specific reasons for dissatisfaction. Their drill-down efforts resulted in the focus on the referral process, and on a variety of specific issues.

In the fourth quarter of 1996, the plan achieved an 85% satisfaction rate with the referral process. The plan continued its focus on the appropriate management of referrals. Through feedback from physicians, the plan identified that it had five different provider directories. This made it difficult for PCPs to determine their referral options. The plan therefore consolidated all the directories into a single, all-inclusive referral directory. To introduce the letter directory, the plan published articles about this intervention in the provider newsletter.

Second quarter 1997 satisfaction ratings with the referral process fell slightly to 82%. This decrease was not statistically significant.

To better understand why members were dissatisfied with the referral process, the plan conducted a drill-down analysis of survey results. They identified the three issues that had the greatest impact on member satisfaction:

• Ease of obtaining referrals
• Timeliness of referrals
• Adequate number of visits per referral

The rapid growth of the plan seemed to be at least partly responsible for continued satisfaction issues with the referral process. Substantial increases in membership (up 23,000) had occurred. PCPs were up 153 and specialists were up 185. The process of utilization management had been regionalized as part of the growth.

These findings led the plan to identify and implement additional interventions in September 1997:

• Provided open access to OB/GYN services. Members were informed through a special mailing
• Included a reference to open access in the new-member handbook
• Sent updated referral directories to all PCPs
• Ensured that PCPs and OB/GYNs have an adequate supply of referral forms, especially in light of the membership growth spurt
• Encouraged sales representatives to remind new members of the importance of establishing relationships with PCPs

The 1998 postintervention data showed a decrease in satisfaction ratings to 79%, possibly linked to several changes in 1997 in the management and operation of the plan.

This health plan's repeated analysis of survey information led to repeated changes in the referral process. Aggressive actions were needed to satisfy its members with utilization management processes. By involving practitioners and addressing their concerns, the plan also made repeated changes in processes without upsetting the practitioners. The result has been a positive outcome for plan, practitioner, and member.