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don’t.” Specialists are also spending less time assessing refer- rals and more time performing billable services. PCPs can review the criteria before submitting referral requests to the hospital’s Access Plus department, which is responsible for referral screenings. If a referral does not meet requirements, an Access Plus staff member sends it back to the PCP along with the section of the criteria that explains why the referral was denied.

“Before this, the reason referrals were denied often wasn’t

clear, which led to frustration and delays. Now, with the cri- teria online, there is no confusion about what makes a good referral,” McWilliams explains. For this approach to achieve the success it has, physicians had to feel comfortable with the quality of the content. McWilliams has heard from his colleagues that they have a lot of trust and faith in InterQual: “The specialists think the criteria are reasonable,” he says, “which helps build credibility with the PCPs.” The criteria have also become a useful teaching tool for residents encountering a complex set of conditions for the fi rst time, an unexpected benefi t to the health system.

In addition, specialists can modify the referral criteria ac- cording to their preferences or the needs of their practices, fl exibility that helps with physician buy-in because they view the criteria partially as their product.

Measurable benefi ts

This revised referral process has engendered better align- ment and good will between physicians and specialists, fueled by smoother interactions and greater understanding of why referral decisions are made. And ultimately, all providers are now seeing the right patients sooner. The process was initially rolled out to cardiologists, with impressive results. Some specifi c benefi ts include the following: Although the number of cardiology staff has remained constant, the wait time to see a cardiologist has decreased dramatically: from an average of 134 days in 2005 down to vir- tually same-day service in 2009. As of January 2012, the wait time for a routine referral to cardiology is only two days. Out-of-network referrals have been nearly eliminated. The number of patients referred to outside cardiologists dropped 98% from 801 in 2005 down to only 22 in 2009, while the total number of patients was practically unchanged. During 2011, only three referrals were made to outside cardiologists, all for special-needs situations.

The same process was subsequently rolled out to all spe- cialists, with similar results. “PCPs are happy because we can get their patients to the specialists in a faster, more appropri- ate manner. At the same time, specialists now see only the patients they need to see. The McKesson solutions make it possible,” says McWilliams. “InterQual is critical to ensur- ing the system doesn’t get bogged down with inappropriate referrals, and enabling us to manage those populations with quality.”


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