Mandatory in network referrals conflict with doctors’ obligation to provide best care

Doctors are obligated to provide the best care possible for their patients. Therefore, doctors should refer patients to other doctors including specialists who they think provide the best care. However, doctors are required by certain insurance or medical practices to refer within specific networks. For example, doctors who belong in multispecialty practices are incentivized to refer within their own practice group. The multispecialty practice provides bonuses to their physicians based on profits earned. Therefore, doctors refer within their own group even though they believe their are better specialists outside their practice group. Even though doctors may indicate bonuses are relatively small and not a major influence, these multispecialty practices track referral patterns and enforce through various means self referral. Insurance companies that require in network doctors are even worse. The insurance companies have high costs and barriers for referring outside of network. Therefore, doctors will not refer outside network even though they believe their patients would be provided better care.

Because these referrals are at the discretion of the doctors and referrals, the manner in which they are applies discriminates against certain demographics such as minorities and poor. For example, two exact patients had brain vasculature malformation were treated differently probably based on their demographics. One patient was white whose parents were a white doctor and white executive, he was easily granted permission to seek outside referral from a major academic medical center. Another patient was adopted latinx whose parents were equally motivated to seek outside referral but were told they would have to pay out of pocket for outside referral. Even the white patient came from a well off family who could have afforded the large out of pocket expense, his doctor and insurance company easily approved outside network care so that they would have to pay the higher costs of out of network payments. On the other hand, the less well off hispanic patient was repeatedly denied out of network referral and therefore, would have to pay the large bills that come from out of network care.

The difficulty in enforcing poor referral patterns is that doctor and care quality can be difficult to measure and subjective. However, there are instances where good care can be more easily measured. Patients with acute stroke should be treated as quickly as possible for best outcome. One standard of care treatment is thrombectomy to remove the clot blocking the artery as soon as possible. So when a patient arrives at a hospital with an acute stroke where thrombectomy cannot be performed, that patient is quickly transferred to a hospital that is capable of performing mechanical thrombectomy. Yet there are hospital networks that will bypass a close stroke thrombectomy center to a further in network hospital.