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Referral management and network leakage reduction were already top-of-mind issues for providers, and thanks to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), they will now be even more critical.
MACRA introduces new formulas to determine physicians’ Medicare Part B payments based on how they perform relative to other providers. Implementation of these performance-based payments will be phased in over the next few years, beginning with data collection in 2017 and at-risk payments in 2019. Referral management will play a key role in determining providers’ success under MACRA, influencing their performance on numerous measures. In addition, several of the new measures for determining physician payments will specifically track how providers manage referrals.
Medicare Accountable Care Organizations are in full swing and healthcare systems are starting to fully grasp what it takes to manage them.
A recently published article in JAMA Internal Medicine explored the largest and most pressing problem with Medicare ACOs: managing the member population. The authors explored the stability of the member populations, network leakage, and proportion of care provided to ACO beneficiaries relative to other patients.
The results from the JAMA research were unsurprising. Medicare ACO populations are extremely unstable, with one in three patients moving in or out of the ACO year-to-year. Leakage to other networks is also extraordinarily high, with 67% of specialty visits occurring outside of the ACO network. Lastly, the amount of care devoted to ACO beneficiaries is only about 38% of the total care provided at a system. These are not the results anyone wants to see – neither Medicare nor providers.
Referral management is an increasingly important part of managing the patient experience and coordinating care within a clinically integrated network (CIN). Yet, often times, referral workflows and trends are poorly documented and misunderstood. Our organization, Fibroblast, a patient referral management solution company, conducted a survey of over one hundred physicians across thirty specialties to quantify how their referral processes work and how they affect providing care. Our data revealed three major conclusions:
Patients do not follow-up
Our data revealed that approximately 33% of patients do not follow-up with the specialist to whom they are referred. That’s worse than the adherence rate for most prescription medications![i] Put another way, only two out of every three patients actually receive the care that they need when a referral is made. This gap in adherence results in higher acuity cases, poor patient outcomes, and millions of dollars of cost to healthcare organizations annually. In an increasingly risk-based environment, providers cannot afford this gap in care.
Check out a great case study on reducing out of network leakage and improving access to care at a major integrated delivery network. here!
Healthcare providers and administrators are under increasing pressure to take a scientific approach to running their organizations. Competitive and regulatory pressures are constantly increasing and the burden of risk is quickly shifting to those who provide care. Physicians practice evidence-based medicine to achieve the best outcomes for their patients. Shouldn’t our administrators use evidence-based decision-making to steer and strengthen our healthcare organizations?
Here are three tactical ways primary care practices can improve the patient referral processes and see immediate improvements in patient followthrough with referral appointments.
1. Dedicate staff members to actively manage referrals
Designate members of the front desk or administrative team as the practice’s referral coordinators. The referral coordinators orchestrate the referral process and track the progress and outcomes of each patient referral. Referral coordinators should be good communicators who work well with patients and providers, both inside and outside the practice. Referral coordinators should also be highly organized, familiar with the practice’s information systems and time expectations for various referrals, and be willing to take persistent action to facilitate and track referrals.
2. Create scalable, repeatable referral workflows to ensure the referral loop gets closed
To the greatest extent possible, the practice should create standardized referral workflows that are scalable, repeatable, and transparent. Too often, referrals are handled ad hoc by multiple members of the staff, using faxes and phone calls to transit patient information and track referrals. That system is inefficient and opaque—patients are lost and potentially catastrophic outcomes can ensue. Rather, all referrals should be routed through the referral coordinators so that the referrals can be tracked. Ideally, the referral coordinators would utilized an automated, end to end referral management solution like Fibroblast, which guides patient referrals to the most appropriate network provider, ensures the timely two-way flow of information between providers needed to complete the referral process, and tracks referrals in real time. After all, the referral doesn’t actually happen until the patient receives the care or services the patient needs; the referral loop isn’t closed until the referring provider receives information back from the consulting provider about the patient’s care.
3. Engage the patient with referral-related messages
The most important and most overlooked stakeholder in the entire referral process is the patient. The most common reasons why patients do not follow up on referrals for care are confusion by the process and frustration over scheduling an appointment. What is more, recent research indicates that 72% of patients would like to communicate with their medical providers over email and 63% would like to communicate by text message. The practice should adopt an automated patient messaging application, like the one offered by Fibroblast. By sending patients automated, preference-sensitive messages about their referrals, the practice keeps patients informed and engaged, greatly increasing appointment attendance rates and promoting better patient outcomes.
FIBROBLAST AND OPTUM ANNOUNCE PARTNERSHIP
Companies form strategic alliance to deliver cutting-edge referral management solutions to healthcare organizations
CHICAGO, IL & EDEN PRAIRIE, MN – Fibroblast and Optum have announced a strategic partnership to bring Fibroblast’s referral management platform to Optum’s suite of comprehensive healthcare solutions. Fibroblast will serve as Optum’s referral management solution under the partnership, available to all new and existing Optum clients. Fibroblast strategically integrates with Optum’s technology and services to provide enhanced value for value-based care, care coordination, and analytics capabilities.
Optum chose Fibroblast after a competitive evaluation of referral management products available to the market. Optum will offer Fibroblast’s full suite of referral decision support algorithms, referral workflow, and analytics tools as solutions. Fibroblast will continue to independently serve its existing clients, while bringing on additional business through Optum and other channels.
Said Scott Vold, Fibroblast CEO and co-founder: “We are thrilled that Optum has chosen our referral management solution. Optum serves some of the most forward-thinking healthcare organizations today. We believe our propriety referral matching technology and workflow management tools present immediate value to those systems seeking reduced network leakage and better coordination of care.”
Fibroblast will be immediately available to all existing Optum clients seeking referral management solutions. Prospective client organizations can contact Optum or Fibroblast to request more information or to see a live demonstration of Optum and Fibroblast’s solutions.
Fibroblast is a leading provider of referral decision support, management workflow tools, and analytics. Its solutions reduce out of network patient leakage, close gaps in care, and provide real-time referral analytics. Fibroblast’s referral management tool algorithmically guides referrals to the highest value, most appropriate providers, capturing incremental revenue, reducing risk, and eliminating administrative expense. For more information, visit www.fibroblast.com.
Optum is a leading information and technology-enabled health services business dedicated to helping make the health system work better for everyone. Optum delivers intelligent, integrated solutions to modernize the health system and improve overall population health. For more information, visit www.optum.com.
On February 2, 2016, Dr. Andrew Albert, Chief Medical Officer at Fibroblast, Inc., led a webinar to discuss how quality measures can help health systems to improve upon their population health goals for today’s newly-chartered world of shifting payment and care delivery models. The webinar hosted approximately 100 listeners and featured speakers Dr. Nikhil Parikh, an Academic Internist, Mr. Robert Sehring, Central Region CEO of OSF Healthcare, and Dr. William Markey, a solo practitioner in the field of Gastroenterology and Internal Medicine. Providing a holistic discussion of population health, the webinar began with a patient interview and ended with perspectives on the future effects of population health on the healthcare industry at large. What follows are the key take-aways.
The status quo for patient care does not adequately promote effective population health management.
As speaker Dr. Nikhil Parikh noted, the job of a primary care physician (PCP) is extremely challenging. With patient routine appointments increasingly being pushed into 15-minute time blocks, PCPs do not have adequate time to ask every question or suggest every appropriate screening for a particular patient. Compounding the issue, many new patients for a given PCP are missing vital health information in their medical records which would have alerted the PCP to perform certain preventative care measures. These systemic frustrations engender a ripple effect from the PCP, to the patient, and onward to specialists and health system leadership. Take the example of the patient interviewed, Margaret, who was diagnosed with colon cancer at approximately 70 years old. Margaret never visited a GI doctor or underwent a colonoscopy until she presented to her PCP with some alarming symptoms. A colon cancer diagnosis is especially devastating since for many patients, it’s a detectable and preventable disease. What is needed are tools to ensure that patients are receiving their early detection screenings: preventative colonoscopy exams are suggested for patients beginning at the age of 45, a full 25 years sooner. The status quo of ignoring preventative care recommendations and presenting to PCPs only once symptoms arise allows patients to slip through the cracks. (For a more in-depth discussion about patients who have fallen through the cracks in the healthcare system, check out our recent blog post Missed Connections.)
It isn’t just patients who experience the status quo strain. Speaker Dr. William Markey described how specialists are inundated with late-term diagnoses for what could have been preventable cases. From his perspective, population health goals are not forced onto specialists per se; however, discussions around new and improved quality goals are now becoming more routine. As such, specialists and PCPs alike are playing increasingly involved roles in population health management, sometimes without even realizing their uniting objective. For Dr. Markey, patient education is at the root of population health. In his opinion, patients should be exposed to more teaching opportunities surrounding the topic of proper health care and disease prevention. Furthermore, he maintains that such teaching opportunities should occur along patients’ entire care continuums, regardless of the difficulty of finding proper tools to facilitate this knowledge transfer. The third undulation occurs at the administrative level. There is no doubt that setting quality goals to propel successful population health management can be daunting. Moreover, the impact of administrative decisions to align with Medicaid and other government program goals must be careful monitored given its flow down to care management practices.
The transition to new care delivery and payment models, coupled with focused measurement of quality goals, is necessary for the future sustainability of healthcare.
Whether taken from the perspective of the patient, PCP, specialist, or administrator, the healthcare market is changing drastically in the areas of delivery, payment, data privacy and security, technology, and beyond. In taking listeners quickly through highlights of the most important recent changes in the healthcare market, Dr. Albert elucidated that each stakeholder in the healthcare industry can feel the ‘ground shaking’ underneath her. One of the most poignant points was the vast difference in various stakeholder agendas. Commercial payors are drastically compressing provider reimbursement rates and upping the requirements and criteria for reimbursements. Government payors are calling for a complete overhaul of care delivery and payment models. Providers require better tools to manage to their business goals while simultaneously maintaining their provision of excellent clinical care; health system administrators are fighting to maintain sufficient margins to keep their doors open. Furthermore, the requirements associated with the ICD-10 transition and the burgeoning EHR interoperability challenges only stress health systems further. Yet progress is being made on the quest to achieve higher-quality, lower-cost patient care.
Quality measures will focus and drive efforts to achieve population health goals moving forward.
When asked, “Is there anyone who will not be affected [by population health goals]?” Mr. Sehring firmly answered, “No, not if we are going to be successful.” As healthcare delivery transitions from today’s emphasis on ‘sick care’ to high-quality preventative care, one hopes that scenarios like Margaret’s will disappear. Increased focus on population health management and quality metrics will benefit all healthcare industry stakeholders. According to Mr. Robert Sehring, a fee-for-service (FFS) payment system is an example of a “misaligned incentive.” From the payors’ perspective, FFS results in higher costs and not necessarily better patient health outcomes. To facilitate the transition to value-based care delivery and associated payment models and attainment of specific population health goals, Mr. Sehring suggests a team-based approach that includes other ancillary services such as health coaches. The linchpin of effective population health management is the delivery of quality care and the attainment of quality measures. Attainment of quality measure goals serves a dual purpose: support for reimbursements and cost management. Plainly speaking, care of specific patient populations cannot be effective without an astute focus on quality.
Fibroblast, Inc. would like to thank Dr. Nikhil Parikh, Dr. William Markey, and Mr. Robert Sehring for their participation as speakers. Fibroblast would also like to extend its gratitude and best wishes to Margaret and her family.
Patients are not getting the care they need, yet employed providers are not at capacity. Health care systems are taking on more and more risk, with little accountable care experience and scant tools to manage risk. How can we satisfy the needs of all parties involved? This one-hour webinar will address the importance of population health as managing risk becomes a more practical reality. Learn how you can mitigate risk through better population health management and health outcomes.
Hear the approaches suggested by a colon cancer patient, primary care physician, gastroenterologist, and a regional health system CEO.