Building a Subspecialty Network


(Appalenia Udell, Esq.) #1

How do you build your subspecialist network (neurosurgery, reproductive endocrinology, peds specific specialties, etc.)? Since subspecialties are usually expensive, how do you work with the system to secure referrals for your patients?


(Robin Dickinson) #2

I think this is a struggle regardless of practice model. Even for ordinary specialists…I only just found an allergist I really like for my patients and I’ve been hunting since years before DPC!

Some of the specialists I “inherited” from older docs at my old job and then just kept when I started my DPC. Others I used to like and are now on my “bad list” because they were completely obnoxious (for example, one subspecialist I used to refer to a lot had done a few things to show he thought PCPs were stupid but then he actually wrote that he adjusted a medication outside his specialty “because I am clearly the only one who knows anything about it who is seeing her”…I was floored and have never referred to him again.)

I have built up my network in various ways…perhaps I knew them from when I was in med school, perhaps I started referring at my old job, perhaps I had a new patient come who just LOVED their whatever-ologist.

The way I finally found an allergist was to start randomly sending different patients to different allergists who seemed like they might be good, telling the patient that I wanted a full report of what they thought, until we found one. I’m curious how other people do this. I’ve heard of “networking events” but honestly, all my favorite specialists are too busy living their lives when they are off work to be doing those.

My criteria for a good specialist is one who is good to the patient (competent, thorough, respectful, can schedule them in a reasonable amount of time, provides excellent care) and who is good to me (never treats me like I’m stupid, sends me a note afterwards, doesn’t make a bunch of referrals to other specialists for things I can do myself, answers my questions if I call, etc). That can be surprisingly hard to find!

As far as expense, I know a handful of places that provide good sliding scale options or a payment plan but for some, I have to tell patients that it’s what insurance is for (for example, I nearly always refer to Children’s for peds). I used to feel guilty about that but the reality is that it’s not my job to solve 100% of the problems with the healthcare system. I’m doing my part but there’s not much I can do about the cost of the brain surgery one of my patients needed recently! And reproductive endocrinology is just always an investment.

Most of my patients are “underinsured” (have high deductibles) and a lot of those insurances will let me do referrals even though I’m not in network. If they have an insurance that requires an in-network PCP, I coach the patients on what to ask for and provide them with a packet of results and a letter from me to the new PCP. Sometimes they will switch but usually they’ll have both of us and the in-network PCP is just there for referrals etc.

I’m curious how other people handle subspecialty needs when they comes up?


(Dr. Peter Lehmann) #3

My challenge is that I live in a monopolized county.

I was actually approached by a Harvard MBA student in the past month. She and others are working on a pilot project to match price sensitive patients (uninsured or high deductible plans) with cash priced specialty care.

When I have a patient I want a specialty service for (could be a consult, a procedure, supervised test, etc) I send her the information of what I need. She and her colleagues are slowly building a database of cash-willing specialists. They find matches and let me know how much and how far away. I am helping them by keeping data on whether the patient is uninsured or HDHP and letting them know what is the best price I’ve been able to negotiate locally (which is squat).

It’s an exciting idea that could really turn into a great service. Right now it’s just a research project and it is all their labor as a grad students about a subject they are passionate about.


(Dr Brian Pierce) #4

Again, this is where telemedicine can play a role. Not replacing our visits or phone calls with patients but by providing a bigger pool of consultants for our patients.

My state is mostly a patchwork of regional hospital network monopolies, especially in rural areas. Almost all consulting specialists work for these high priced networks and are a long distance away. They also have long waits which leaves me managing complex patients until I can beg their way into an earlier appointment and because of the long waits the consultants have little incentive to improve their service to us or our patients.
With enough DPC and independent practices that would participate, we should be able to attract a telemed firm to get licenses for specialists in our state. That won’t drop the consult prices as much as what we see with labs and imaging but it would go a long way towards fixing these problems and give patients yet another incentive to join a DPC.


(cjs56) #5

Telemedicine would be the best solution. Or, you could call the local Federally Qualified Health Center and ask who they use for specialty referrals. The reason is that …if a specialist would take a Medicaid H.M.O. patient, then that specialist would probably take a D.P.C. patient for a discounted rate. That may solve the access problem.
You will always find snobby specialists. I have not seen too many in California (but there are some) and some some in Chicago… but… saw… many,…many …many… in New York during a couple of years general surgery training before family medicine.
Just do not refer to them unless you have to (your D.P.C. patient really needs it).
Has anyone read…The Doctor’s Guide of Concierge Medicine? It is written by the team that writes for the Direct Primary Care journal.


(Dr Brian Pierce) #6

It isn’t that consultants (remember family docs are specialists too) are snobby, they’re simply busy enough dealing with their current problems and my patients’ waits and high costs aren’t high on the list of things the consultants feel they need to fix.

The consultants are almost all hospital employed. They no longer know nor have any control over their prices. You would need to approach the hospital networks CEO or COO about the discount. Good luck with that.


(John Lin) #7

Those consultants who don’t realize that when patients want to be seen, they want to be seen right now, are missing the boat and a great opportunity. Believe it or not, there are still docs who think having a patient wait list is a badge of honor. I call it inefficiency, lost opportunity, and simply poor management.


(Robin Dickinson) #8

Thank you for this! Because we certainly are. I just explained this to a patient recently. He thought consultants know everything we know plus their stuff too! I rattled off everything I learned in residency (how to delivery babies, manage bipolar disorder, do joint injections, biopsy suspicious lesions, manage diabetes, do well baby/child/woman/man visits and address problems as they arise, apply casts, read EKGs and xrays, care for ICU patients, etc, etc, etc) and that the doctor I was referring him to had spent 1 year learning basic adult medicine and 3 years learning about nothing but skin.


(cjs56) #9

Give them the “ol Chicago Line”:
Family Medicine is the study and specialization of all organ systems and patients without regard to age.
That will usually give specialists and patients food for thought.