Patient leakage from a health system network is an emerging critical issue facing healthcare leaders. As Medicare and Medicaid reimbursements continue to negatively affect operating margins for even high-performing health systems, competition for privately insured patients is increasing. To compensate for flat or shrinking fee-for-service revenue from the Centers for Medicare and Medicaid Services, many health systems are participating in the agency’s value-based care payment programs; while this presents new revenue opportunities, it also puts pressure on systems to improve outcomes.
Adding to these challenges is competition among health systems as consolidation continues to shrink the number of players in markets. Ensuring your organization remains dominant, or even competitive its market, depends on your ability to attract new patients and retain them in your network. If they do leave, it’s critical to identify the leakage immediately so that steps can be taken to “repatriate” those patients back into your health system.
It doesn’t matter whether you’re operating under fee-for-service or value-based care contracts (or both). In every case, there are financial repercussions from patients going somewhere else for care.
Leakage can occur at any point in a patient’s journey, from referral to transport to admission to discharge and beyond. One important juncture for addressing leakage is during the patient transfer process—for example, when a patient needs specialty care.
Navigate For Referrers And Patients
The most crucial fork in the road between retention and leakage occurs when a patient arrives at his or her community hospital’s emergency department (ED). The experience that a referring hospital’s physicians have communicating and referring through your transfer center is often the difference between losing and retaining a patient.
Let’s consider a scenario where a patient presents to the community hospital ED with stroke-like symptoms. A workup reveals a large vessel occlusion (LVO). It is clear to the ED physician that the patient should be transferred to a comprehensive stroke center for endovascular therapy (EVT) and thrombectomy.
The ED physician calls your health system to arrange for transfer but must first navigate numerous phone menus. Ultimately the hospital operator connects the physician with the nursing supervisor (who often manages patient transfers). The nursing supervisor, though confident your hospital can help, is not certain which physician to contact for this type of transfer (Hospitalist? Neurology? Interventional radiology?) and also whether or not there is bed capacity. Additionally, the on-call schedule is not clear because of constant changes.
The nursing supervisor enlists the help of the neuro-unit charge nurse, who knows the process better. They send several text messages and make multiple phone calls (in between their other numerous duties) in an attempt to contact the appropriate physician. The process is lengthy because there is no standard workflow, and physicians often take a while to respond.
Meanwhile, precious minutes, potentially hours, tick by while the community hospital ED physician grows more frustrated and concerned for the patient’s status, and ultimate outcome. Rather than further delaying care, the physician calls the other comprehensive stroke center in the area, and has a much different, much more positive, experience.
How Patient Care Orchestration Should Work
The other health system that the emergency physician calls, in contrast, has an optimized transfer process. That means only one phone number needs to be dialed to access and arrange for any type of care available across the network. The referring physician can expect to speak with a skilled and experienced transfer center professional who can knowledgeably discuss the patient’s condition and needs.
While on the phone, this transfer center’s agent begins contacting available, on-call specialists who need to be consulted and approve the admission, and views bed capacity in the health system’s stroke center. The agent is able to perform these tasks so fluidly because of technology that offers a comprehensive, real-time perspective on the health system’s facility capacity and physicians’ schedules, so they can easily identify on-call status and availability.
This health system’s leadership has formally designated and communicated that growing patient transfer volume and reducing network leakage is mission-critical, which means on-call physicians promptly respond to consult requests. Instead of waiting hours for a callback, the community emergency physician is promptly connected with the appropriate physician and has an approval for transfer in less than 10 minutes. Simultaneously, agents are communicating electronically with the available transportation vendors. As a result, the ambulance is on its way before the physician hangs up the phone.
Apart from the lost revenue from the patient who was transferred to a competitor’s stroke center, your health system may also end up paying for that care. The patient, unbeknownst to clinicians involved in the lost transfer, was attributed to your accountable care organization. This means you just signed up to pay for all costs associated with the patient’s care at the competitor’s acute care facility, and run the risk of paying for services provided in post-acute rehab, and even outpatient follow up.
Retention And Repatriation Are Essential
Beyond acute care transfers, a fully optimized patient retention-focused strategy would ensure the health system follows up with the stroke patient after discharge to ensure she’s feeling well and following a plan to prevent another incident or readmission. When she needs to see a specialist for a different condition, the right staff person would see that need within the integrated technology and proactively connect her to the right in-network facility and would ensure her transportation needs are met as well. All of these steps are essential elements to retain a patient within a network.
Strong transfer center technology merged with high-performance processes would also offer agents or care managers analytics capabilities to deliver actionable insight on leakage trends across facilities, providers and referrers. The technology, for example, would generate reports that could be used for outreach to repatriate patients back into the network. Keeping patient in network helps ensure high-quality care prevents overutilization of high-cost resources that can impact outcomes and value-based care reimbursement.
Organizations focused on streamlining referrals would likely incur less leakage of patients and of revenue, no matter the types of contracts they have in place with payers. They would also likely see an uptick in patient satisfaction, which is vital for retention. After all, of the two transfer situations described above, which patient do you think had a more satisfying experience? I’d be willing to bet it’s the one who received the right care at the right location without delay.
In the near future, transfers will become much more than moving patients emergently to the appropriate hospital or specialty center. They will evolve into care access gateways, so health systems can deliver care and provide services to maintain retention across the continuum. These new “access centers” will be the heart of patient care orchestration and will be integral to every type of care from the hospital, to post-acute, to telemedicine to home.
About The Author
Angie Franks is the CEO of Central Logic, a company that partners with leading health systems to deliver an enterprise-level view of every point of access within their system, and the tools needed to accelerate access to care, increase revenue, and become the health system of choice in their market.
*Originally posted in Health IT Outcomes.