In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.
Practical Considerations
Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.
The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.
And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.