From now on, the majority of Yale Health Plan patients will be referred to Yale Medical Group physicians for specialty care and rarely to community physicians outside of Yale.
A new Joint Operating Committee is formalizing the referral relationship between YMG — a multispecialty group that comprises the clinical faculty of the Yale School of Medicine — and the Yale Health Plan is behind the change, among other referral changes. Before the creation of the committee, roughly 85 percent of YHP patients were already referred to YMG physicians. But the change will bump up that number to nearly 100 percent.
The number of specialist referrals in total will also decline with the integration of e-consultations and e-visits, in which primary physicians provide early stage care specialists would have otherwise provided. While concrete plans for how to implement specific aspects of the referral changes will be fleshed out in 2015, clinicians and administrators interviewed said that the change will improve the quality of care while also pushing down costs.
“[K]eeping the cost of our plan affordable requires that we use specialty care only in the situations where it is truly necessary,” said Yale Health Medical Director Michael Rigsby MED ’88 in a Monday email, referring to the use of e-consultations and e-visits.
According to YMG Chief Medical Officer Ronald Vender MED ’77, the Governance Committee is merely formalizing a relationship that has been evolving for years. He added that with the nearly 15 percent increase in referrals to YMG physicians from YHP, exceptions that allow YHP members to go to outside physicians will be made only in very rare circumstances. In cases where the community practitioners with whom Yale had previously worked were outstanding, Yale merged with those community practices, which included a medical oncology and haematology group that is now part of the Smilow Cancer Hospital. .
“Although the YHP has worked with a number of YMG specialty services for many years, the global, exclusive agreement between YMG and Yale Health for all specialty services is a very new development,” Rigsby said. He added that the change is unlikely to be immediately obvious to most YHP members and will only impact students who have not waived YHP in favor of their parents’ plan — a minority of undergraduates.
Rigsby, who is leading the new committee, said that the change was prompted by concerns about increasing health care costs. With the Affordable Care Act, dependents are able to stay on their parents’ health care plans until they are 26. That means that Yale employees — the main users of the plan — are costing the university more because their dependents are covered for longer, Genecin added.
Keeping referrals within YMG keeps the money within the Yale system, Chief of Student Health and Athletic Medicine at Yale Health Andrew Gotlin said.
Vender added that the move had not been attempted before because YMG simply was not capable of taking all the referrals. But those days are over, he said.
In addition to keeping referrals within the system, the new changes will also decrease the number of specialist referrals. With e-consultations and e-visits, primary care physicians will give more specialist care with the aid of standardized guidelines and pamphlets. Patients will get preliminary testing and scans in advance of seeing a specialist, thus making more efficient use of specialist time, Rigsby said. He added that the exact mechanics of the new e-referral program will be finalized in the new year, but will be a continuation of the modern trend some have dubbed the “decentralization of healthcare.”
The move to e-consultations and e-visits were prompted by the high cost of specialist physicians’ time, Vender said. He added that over the next six months, the operating committee will be creating referral guidelines in collaboration with YMG and YHP on which criteria should be used in recommending extra consultation.
In January 2014, Yale Health launched its new electronic health records system, Epic.