Accountable care organizations (ACOs)–groups of doctors, hospitals, and other medical care providers–have a trio of goals: to provide high-quality care, to coordinate efficient care for patients, and to reduce healthcare costs. Patient leakage can represent a major impediment to reaching these goals. While it is only one factor that can affect the success of an ACO, it is an important one.
WHAT IS PATIENT LEAKAGE?
Out-of-network patient leakage, also sometimes called network leakage or referral leakage, occurs when patients are referred to healthcare providers outside the ACO. Sometimes this is unavoidable, such as when a patient needs emergency care while traveling far outside the reach of the network or when the only specialist or after-hours provider available isn’t part of the ACO. However, too often, patient leakage occurs because an in-network provider actually refers a patient to a provider outside the network.
WHAT IS THE IMPACT OF OUT-OF-NETWORK LEAKAGE?
When patients seek care from out-of-network providers, they are essentially buying into un-managed care. The out-of-network provider has not committed to the quality standards, procedures, and cost management that in-network providers have. This means a few different things. First, the ACO no longer has control over ensuring that the patient gets the high-quality, efficient care he or she needs, and second, coordinating care among in-service and out-of-network providers can prove difficult and time-consuming. Third, the fees the employer, insurance company and/or patient has to pay may be much higher than the fees set by the ACO. Additionally, when fewer patients depend on the services of ACO providers, that translates into less revenue for the ACO.
SHARED SAVINGS: WHY IS IT IMPORTANT?
One of the primary goals of an ACO is to improve care, efficiency, and value for patients. By working together, an ACO’s care providers can often achieve this goal while also reducing operational costs. Thanks to the reduced costs, there are savings, which can be distributed among ACO members and the parties responsible for paying for care. A high level of network leakage threatens not only the goal of reducing costs but also this shared savings.