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
Marci Lait
Ms. Lait, Though you do raise valid legal concerns. But, whether you realize it or not, your comments are VERY disjointed from what the large majority of the patient population is truely concerned about. 1. COST!!!!!! That is the first question out of the patients mouths when they are informed of their options or being referred. "Is that covered?" "Is that expensive?" Knowing the Insurance network is often multiple phone calls blindly until the staff learn through elimination which INS is accepted where......Then it changes the next year, and you start over again. 2. Distance to the care. In rural America distance and travel to relevant care are true barriers. I am located about 2hrs outside of Atlanta and the traffic can push that to 3hrs travel. Geographic access is a real factor in referral decision making. 3. Tracking the patient flow are and referral process are necessary for a patient centered practice and informed primary care providers. Trust is earned, and the PCP's typically have earned it and don't want to jeopardize that relationship, nor the patients health simply by being in the dark. Patients want the specialist they see to be knowledgeable about their entire medical needs AND the developing situation. Patients also want their PCP to be kept up to date and their evolving care with specialists. They like the idea of PCP's looking over the shoulder of the specialists. Patients want eyes on their problems. 4. Satisfaction- If customers are not satisfied, patient engagement declines, care waivers, poor outcomes increase, and cost will increase. I don't know how your networks are operating but when providers find specialists that perform, that is where the patients will be sent first every time. Otherwise, the aforementioned problems are going to grow and the PCP's are the ones who will be left trying to fix it all. 5. Tracking and reporting are paramount to knowing where you stand, and how identified problems are remedied. Having analytics to monitor the process only serves as a tool to improve the process. I have no knowledge of, or affiliation with this software, nor am I advocating it's use. I am simply utilizing experience based on the based on many different levels of practice I have as a RN and Quality specialist, both in hospital and in the outpatient/physician office, both specialist and primary care, both small practices and LARGE regional multi-specialty health systems covering millions of lives. This tool touches on the primary points of concern around the referral process, form both the patient and the providers side. Don't let the threat of regulation deter you from advocating for patients, improved care for them, and possibly improved outcomes. Innovation and improvement - that's why the big guys are big, and getting bigger. But that also means the target on their backs are also getting bigger! I have felt the pain of one-doc shops, don't think I am unsympathetic. I have often found that the large health systems with lots of resources often like to coordinate with and assist the smaller practices in many ways. The bread crumbs of giants are feasts for mice. It sometimes takes time and effort on the part of the smaller practices to find these alliances. If you learn how to draft in with them rather than get caught in their wake and washed aside. their are many benefits. I have been involved with smaller practices and found that they will tout their care is as good or better than the big guys. The difference is the big guys back it up with data. When they are failing they use the data, scientific process, and PDSA cycles to improve. Don't be afraid to steal pages from the big guys play books, many times if you ask they will freely give it to you and support you in your processes. They do this because they know that many of your patients are also their patients too. Your patients go to their hospitals and their specialists or vice versa. Patients will gravitate toward the better quality and outcomes. Be ahead of the curve and point them in the right direction and you will be the hero.
Brantley Moore

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3-minute case study: Plug that leak!