3-minute case study: Plug that leak!

  | October 10, 2017

What innovations drive success in healthcare? Here's a tactic from a leading health system.

The problem

Nationwide, some 25 percent of referrals made by employed physicians go to out-of-network specialists. Arizona Care Network (ACN), an innovative, clinically integrated network in the Phoenix area, saw this "referral leakage" as low-hanging fruit, an easy way to make a dent in the 60 percent of patient spending taking place out of network.

The solution

ACN's 5,500 affiliated physicians intuitively understood the need to keep referrals in network. The challenges was to provide them with real-time data about which specialists are in-network, and then facilitating coordination between referring providers and those specialists. Ed Clarke, M.D., ACN's chief medical officer, turned to technology to solve the problem.

All ACN practices were given access to a web-based digital map that calls up a directory of ACN specialists who perform procedures in facilities that align to ACN's care standards and practices. According to Clarke, “We know that when events occur in these facilities, in almost all cases, the total cost of the event is reduced compared to when they go to our competitors."

When a primary care physician in the network initiates a referral, the directory only shows specialists who accept the patient's insurance. The request is placed directly in the appropriate specialist's queue. And a text is automatically sent to the patient, letting him or her know the request has been made.

Specialists must accept or decline referrals within 48 hours. If accepted, they can request and receive all relevant patient health information electronically. Their office then contacts the patient directly to schedule an appointment.

Once they have seen a specialist, patients receive a patient-satisfaction survey electronically, and their review is shared with both the specialist and their own doctor. Ultimately, as satisfaction data grows to a critical mass, it will be integrated with the map, enabling primary care doctors to sort specialists by patient satisfaction scores when making referrals.

The outcome

As of September 2017, ACN retains 89 percent of referrals in-network. Patient wait times have been reduced by streamlining the communication between primary care providers and specialists and erasing the usual delay in response time from specialists contacted by fax. And patients appreciate that an always-current list of in-network specialists synched with their insurance coverage reduces the chance that they will be hit with out-of-network charges by their insurer.

“If we can have our specialists align with our in-network facilities," says Clarke, "especially for high-cost procedures such as joint replacements and oncology referrals, if we can steer those in-network out of the gate, we potentially can redirect millions of dollars."

Lia Novotny is a frequent contributor to athenaInsight.

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Not appreciated!!!!!!! As an independent physician in the world of Hospital Owned physicians, this is anathema. Although it is not strictly a violation of Stark Laws, it is not necessarily best practice to keep patients in network for the financial benefit of the network when their needs may be better served outside the network. This article underscores how big corporations somehow slip through the regulatory cracks that we smaller providers must tediously navigate. On the other hand, if big corporations think along the lines you mention, they could become a statistic with a multimillion dollar settlement
Name: 
Marci Lait
Email: 
marci@bluewaterentobx.com

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3-minute case study: Plug that leak!