Costs of Specialist Referrals From Employer-Sponsored Integrated Health Care Clinics Are Lower Than Those From Community Providers

Abstract

Background: There have been very few published studies of referral management among commercially insured populations and none on referral management from employer-sponsored health centers.

Objective: Describe the referral management system of an integrated employer-sponsored health care system and compare specialist referral rates and costs of specialist visits between those initiated from employer-sponsored health clinics and those initiated from community providers.

Design: Retrospective, comparative cohort study using multivariate analysis of medical claims comparing care initiated in employer-sponsored health clinics with propensity-matched controls having specialist referrals initiated by community providers.

Patients: Adult patients (≥ 18 years) eligible for employer-sponsored clinical services incurring medical claims for specialist referrals between 12/1/2018 and 12/31/2020. The study cohort was comprised of 3129 receiving more than 75% of their care in the employer-sponsored clinic matched to a cohort of 3129 patients receiving care in the community.

Intervention: Specialist referral management program implemented by Crossover Health employer-sponsored clinics.

Main measures: Rates and costs of specialist referrals.

Key results: The relative rate of specialist referrals was 22% lower among patients receiving care in employers-sponsored health clinics (35.1%) than among patients receiving care in the community (45%, p <0.001). The total per-user per-month cost for patients in the study cohort was $372 (SD $894), compared to $401 (SD $947) for the community cohort, a difference of $29 (p<0.001) and a relative reduction of 7.2%. The lower costs can be attributed, in part, to lower specialist care costs ($63 (SD $140) vs $76 (SD $213) (p<0.001).

Conclusions: Employer-sponsored health clinics can provide effective integrated care and may be able to reduce avoidable specialist utilization. Standardized referral management and care navigation may drive lower specialist spend, when referrals are needed.

Keywords: health economics; referral management; specialty care; team-based care.

Figure 1

Patient paths among internal referrals. (a) Patient paths from primary care. (b) Patient paths from physical medicine. (c) Patient paths from behavioral health. Legend: These schematics describe the flow of patients from an initial visit with providers in one clinical discipline to the other disciplines at the employer-sponsored clinics. Each patient is denoted by a gray line; thus, the size of the gray bar represents the proportion of patients experiencing primary care at first visit and transitioning to the same/other clinical disciplines for subsequent visits. Lines that end in white denote the end of an episode of care. Because each panel represents all of the referrals originating out of each clinical discipline, it is important to note that they are not on the same scale (since there were vastly more patients seen in primary care than in behavioral health).

Figure 2

Specialist referral rates over time.