Referring Badly

So when Rady Children’s Hospital in California contacted Molina’s Medicaid plan this year, the intent was not at all about themselves. They called to warn about a significant increase in referrals to their pediatric rheumatology unit from community clinics, which may seem counterintuitive but the problem is the referrals were not in line with clinical guidelines—many patients lacked clinical history suggesting they even had a rheumatologic disease. Necessary lab tests and imaging were often not completed and, when they were, referrals were frequently based on inappropriate labs, like positive results of an antibody that may indicate autoimmune disease. About 20% of healthy children and adolescents may test “high” for this antibody (called ANA), but our Molina source said this does not indicate rheumatologic disease on its own. Family history of rheumatologic conditions is also not a referral indication without supportive clinical symptoms and findings. These community clinics, constrained by a lot of patients and not enough staff, are not fully trained in when and when not to refer and many clinicians default to sending the patient to the hospital for liability reasons. This is exacerbated in the Medicaid population. I know it well from a community in Hartford where I’ve lived most of my life where a large portion of the Medicaid population there consider the ER their primary care. Molina is trying to educate clinicians and advise more PT and pain clinic referrals as alternatives.  This story points to a broader issue in my opinion in healthcare that has always been present – we need better triage and better educated frontline clinicians for mental and physical health, better educated on rare disease and even common ones, more attention to the clinical utility of ordering tests, and more careful referral.  An ER in the northeast had a similar issue with an influx of Medicaid adolescents referred for headaches that the urgent care provider thought could be vision issues or a possible tumor, leading to observation costs, unnecessary IV therapy and sometimes CT scans, even when the most common cause was anxiety and depression.  Many PTs and athletic trainers acknowledge as my own dad did about the difficulty identifying the root cause of pain particularly when there’s underlying addiction or eating disorders….The patients themselves are in a tough spot because they are relying more and more on google for advice amidst a lack of primary care and often conflicting medical opinion – one doctor suggests surgery for a meniscus tear, the other suggests waiting it out. One suggests gut or celiac disease, the lab tests are negative, but the symptoms persist, leaving patients in a circle of unknowns. I’m lucky having been connected to a family of PTs so deciphering injury diagnosis and treatment has been easier to navigate but most folks don’t have that….Maybe the growing investment in care coordination and so-called tech-enabled companies is promising but many of these businesses are largely still focused on site of service re-direction, not as much as pure diagnostics. If you’re trying to get the attention of a consumer or an insurer, shrinking the time to the answer is a good starting point, particularly since turnover from insurance plan to plan is so high. One question to be asking when you evaluate these coordination or tech-enabled companies is who’s coordinating what and are they solving the problem or simply adding a layer to it….I was in an board meeting at regional health insurer this summer and the presenter put up an org chart of a care management vendor that had pitched the insurer to take over work for special populations – pain, mental health, elderly.  The chart resembled the NYC subway map – “looks nice, doesn’t it,” the presenter said. “All of these case managers, all of this tech enabled integration. These are big promises they are making. But what’s missing?” After a set of stares and ums from the group, a nurse on the committee said “the doctor.”  Yes, where’s the doctor, where’s the physician who can help use clinical judgment on referrals, who – if trained in figuring out what’s wrong like TV’s Dr. House – can hopefully flag disease or get to “treatment plan” sooner and make the journey for that patient a whole lot smoother.  It’s a fair question and an important one to be thinking about—so important we just had a hospital in California complaining that the frontline community clinics are referring people to hospital-level care they don’t need.  I suppose there’s good intention, but that inappropriate referral comes with a cost—to the state, the taxpayer, the hospital’s time and resources and, well, it cost moms and dads and their kids the most. Their time and stress and sanity.