Case Studies: Inappropriate Referrals

Problem:

A large integrated health system has received a large number of complaints from both primary care providers and patients regarding how the system handles chronic pain patients. Costs of managing these patients are extremely high and include pain medications, diagnostic testing, and specialist utilization.

Process:

• Collection and analysis of claims and encounter data related to chronic pain.
• Interviews with key stakeholders in the system including primary care physicians, pain clinic staff, specialists, and administrators.
• Focus groups with chronic pain patients.

Solutions:

• Restructuring pain clinic for better patient access and a more appropriate mix of services offered.
• Development of patient education in order to improve patient compliance and to give patients some control over their own condition.
• Physician education interventions aimed at better management at the primary care level and a reduction of inappropriate referrals to the pain clinic.

Opportunities:

The HPC process identified underlying root causes of the costs and complaints, and suggested a change strategy which included health system changes as well as patient and physician interventions.