In the ideal world, the primary treating physician is a member of the employer_s panel.
That ideal panel would consist solely of the most competent clinicians in the community.
The primary treating physician would refer to the most competent board certified specialists and subspecialists based upon the implications of the patient_s symptoms, diagnostic studies and consequent needs.
However, the referral process may be greatly, and perhaps unnecessarily, compromised.
Clinicians may refer based upon factors other than competence, the most common of which is friendship, to others within the same office, or to show appreciation to someone who has referred to them.
The clinician may delay or avoid a referral because the employer or insurer would be displeased. In many cases, the primary treating physician is fearful of disapproval from the insurer or employer (and retaliation in the form of receiving less/no cases from them).
(I reviewed medical records on a case recently in which the surgeon said “this patient needs a psychological evaluation…I am not making that referral and not saying it needs to be made…but the patients problems are psychological…but it is not a referral I am making at this time….)
Perhaps the most alarming situation in the workers_ compensation system is that referrals are made, blocked, redirected, encouraged or coerced by those without any health care training. In those cases, you have non-doctors making decisions about medical necessity and appropriateness. This occurs in situations where the interfering party is trying to cost-contain or trying to case build. These non-clinicians want to govern the data that appears in the chart by hand selecting clinicians over whom they feel they have control.
The solution is both simple and direct:
a. build effective panels of the best credentialed, most thorough, and consistently objective clinicians.
b. Provide those clinicians with access to the most competent subspecialists available.
c. Do not abandon a provider if an occasional case does not go the direction you would have preferred, and verbally reward the doctors for excellence in patient care and most of all,
d. respect their competence to chose the best providers to whom to refer rather than allowing the referrals to originate from non-clinicians.