Understanding How Providers and Staff Make Decisions About Where to Refer Their Patients: A Qualitative Study.

Value-based payment incentivizes primary care providers (PCPs) to refer patients to specialists inside their own organization. "Outmigration" of patients to specialists in other organizations is common, yet why it occurs is not clear. We conducted qualitative interviews of PCPs, nurses, and administrative staff at primary care practices in a physician organization (PO) to determine reasons for outmigration. While participants reported that they preferred making within-PO referrals, they identified 18 barriers to within-PO referrals, which often led to patients receiving care elsewhere. Many of these barriers are potentially modifiable and could inform the design of future interventions to decrease unnecessary outmigration.