Health providers throughout the world rely on patients in order to practice and stay in business. Whether as part of a hospital, health network, or private practice, healthcare practitioners depend on incoming referrals from other health providers and entities.
Providers tend to refer patients to other providers within the same hospital or health network. This is mainly due to them all being under the same health plan umbrella.
For example, any individuals that join Kaiser Permanente and enroll in the Kaiser Foundation Health Plan primarily receive their medical services at Kaiser Foundation Hospitals or regional Permanente Medical Groups.
Private providers refer patients based on numerous factors, including personal relationships, quality outcomes, proximity, and most importantly, patient preference.
What is Patient Leakage?
Patient leakage denotes the process of patients seeking out or being referred out of network by healthcare providers. Accordingly, patient leakage is sometimes known as network leakage or referral leakage.
Let’s go over some definitions first.
In-network refers to care within a network of doctors, hospitals, and other health providers that an insurance company has contracted with. Patients that seek care within their network are seeing only those providers that their specific insurance company has agreed can be seen under the terms of the insurance. In-network care is cheaper due to discounted rates that an insurance company has negotiated ahead of time with the various health networks.
Most insurance companies contract with managed care consortiums such as health maintenance organizations (HMOs) or preferred provider organizations (PPOs).
Out-of-network refers to patients looking for or being sent for care outside of their current health network. This means that they seek care outside of the network of providers that their insurance has arranged for. As mentioned above, patients seeking care or being referred out-of-network is the main reason for patient leakage.
Most health care organizations don’t realize the amount of revenue that is leaking out.
Below is an example of a large multi-state health system called Dignity Health. This graphic shows only a small subset of money that they are leaking out to competitors in the state of California. Extrapolating from this information, we can predict that most health systems are losing on average anywhere from $200 to $500M per year to competitors.
A solution like referralMD’s specialty care network management solution can help save a health system millions.
Health Maintenance Organizations (HMOs)
HMOs, give you access to doctors, hospitals, and care centers within a certain health network. All of these providers in-network are held to certain quality standards and contracted to provide care at lower rates to those enrolled in their plans. However, HMOs only allow for care to be covered by providers within the network. This is not true for other managed care entities.
Preferred Provider Organizations (PPOs)
The other big type of managed care organization is the PPO. PPOs are very similar to HMOs in that they provide discounted rates to providers within their network. However, there is a lot more flexibility under a PPO plan. There are fewer restrictions on seeing providers that are not in your network.
Here is another great resource further outlining the specific differences between HMOs and PPOs.
How Does Patient Leakage Happen?
Sometimes patient leakage is unavoidable. For example, when patients require certain care or treatment that is unavailable within their network, then a referring provider must accommodate to the patient’s needs.
However, there are occasions where in-network providers may refer patients to out-of-network providers on purpose.
The reputation of the Provider
Sometimes, a provider will refer their patients out-of-network in order to have them see another provider who is more reputable in a certain field, specialty, or procedure. This could be due to a current health network not employing a reputable specialist or employing someone who is not as experienced or successful. In the end, a provider is responsible for their patient’s health and well-being. Therefore, ensuring that a patient gets the best treatment possible trumps any in-network loyalties.
That being said, most large health networks do employ some of the most successful and well-renowned health providers out there. For example, Massachusetts General Hospital (MGH) in Boston, MA has incredible brand recognition because their physicians are some of the most recognized, highly rated, well published, and experienced doctors in the nation. This is a prime example of how patient leakage occurs. Many patients having elective procedures or surgeries will tend to go out-of-network to large academic hospitals, such as MGH (affiliated with Harvard University School of Medicine), due to the stellar reputation of their facilities and their physicians.
Lack of Knowledge or Insight
Providers in a community that have just joined a health system do not yet know about the specialists in their network. This could cause some confusion when it comes time to refer a patient somewhere. If a system doesn’t do a good job of having specialists laid out or making it easy for providers to refer within network, then there is a much higher chance for patient leakage.
When certain care is not available within a network or a patient is thinking of going out-of-network for some reason, then it is up to the provider to listen to the patient’s needs and recommend a next best course of treatment. Patients do tend to take the provider’s judgment into their final decisions, but ultimately, the choice is up to the patient. This is why certain amounts of patient leakage will always exist.
Why Is It Bad?
Missed Revenue and Reimbursement Opportunities
The main problem with patient leakage is the missed revenue opportunities for health systems. These organizations miss out on reimbursement for medical services that are provided elsewhere. This is especially important in those systems that adopt value-based care or payment models, such as accountable care organizations (discussed further below). When patient leakage does occur, these health networks lose the ability to manage patient care and cost, effectively altering reimbursement structures.
Lose Chance to Establish Relationships with Referring Providers and Patients
Another problem with patient leakage is that providers lose out on building relationships with referring providers and with patients. Many health systems have spent resources on building clinical alignment through quality based care models and uniform EHR (electronic health records) software. Unfortunately, when patients go out of the system, providers lose the ability to coordinate care, which is a key element to building relationships among referral networks.
Also, when patients leave a network, then there is more likelihood that they will choose to do so again for other medical care. They may even choose to change their insurance plan and leave a health system entirely. This is not as likely if the provider can establish a strong relationship with his or her patients, and persuade them to stay within the network for their care. A provider that can do this is also more likely to be respected within the system and be sent referrals in turn.
Lack of Coordinated, Efficient Care
As mentioned above, patient leakage is particularly troublesome for organizations that have established value-based care models. Once a patient leaves a network at any point of their treatment or care, then they are no longer subject to the efficient, data-driven care associated with that health system. It becomes much harder to coordinate care amongst that patient’s providers, whether it be a difference in EHR software or an unfamiliarity between those providers.
Who Does It Affect?
Large Health Networks/Systems
Health networks and systems are very prone to patient leakage. As we discussed above, HMOs and PPOs offer insurance plans that require patients to see certain providers only. When a patient is sent or seeks care outside of that health network, then that system loses out on reimbursement and revenue opportunities.
Accountable Care Organizations (ACOs)
ACOs are healthcare entities composed of doctors, hospitals, and other health providers that are committed to payment and care delivery models focused on improved quality and lowered costs.
Patient leakage is a huge barrier to ACOs in accomplishing their goals. This is because once a patient leaves the ACO network, they are effectively obtaining un-managed care. Health providers outside of the ACO network do not adhere to the same quality or cost standards. Indeed, it becomes a huge challenge to coordinate care among the ACO and the out-of-network provider. Additionally, the ACO loses out on the revenue that offering those medical services would have provided.
Small Healthcare Providers
Small health providers are also affected by patient leakage. Most private providers have the freedom to refer patients to whomever they wish. Well established providers within a community tend to refer patients based on personal relationships and historical precedent. Newer providers may look to refer to other providers based on factors like location, patient reviews, advice from colleagues, etc.
Recently, many practices and groups are being purchased or aligned with larger health networks. Within smaller communities, these networks hope to exert their influence by contracting providers to refer patients to their regional facilities for all medical care. This has largely been successful, yet sometimes patient leakage does still occur due to many of the reasons detailed above.
A relatively new development has been patient leakage to on-demand telehealth providers. Many new telemedicine applications are offering e-consults, at home doctor visits, and online prescription deliveries, just to name a few. By offering previously unknown value in the healthcare industry, these innovative companies are siphoning patients from traditional institutions. This patient leakage is sure to continue in the future as more telehealth providers emerge with services making it easier and cheaper for prospective patients to receive medical care.
Last but not least, insurance companies are also affected by patient leakage. Many of these companies agree to discounted rates with certain healthcare providers in their plans. They then offer these plans to the public with the expectation that they will use the aforementioned organizations and providers for all of their healthcare needs. This is not always the case, and patients do end up seeking care out-of-network for one reason or another. Unfortunately, these insurance companies are left to pay much higher rates to the out-of-network providers than they would normally if their patients had seen providers in-network.
How to Combat Patient Leakage?
Organizations can combat patient leakage by ensuring that they employ the most respected, experienced, and well-regarded providers that they can find. This should help with patients that choose to voluntarily go out-of-network for care that can be provided within their current health system.
Another excellent way to combat patient leakage is to enhance the patient experience. There are a couple of tips that can help your system accomplish this:
Make sure that there is clear communication between physicians and patients.
Having clear communication between providers and their patients is key to creating a positive patient experience and engagement. For example, approving a standardized EHR software across the continuum of care allows for convenient and direct access to a patient’s medical records for all of the providers within the network. This not only lessens the burden of the providers but also eases the patient’s responsibility of having to reiterate the same information multiple times.
Also, a health system can decide to give patients control of their health by implementing e-consults and other software that allow patients to schedule their appointments, talk to providers online, order prescriptions, etc.
Be transparent in all aspects of care.
- It is important to have prices and pricing structure available to patients. In this day and age, patients are taking more control over their healthcare and their healthcare costs. People are “shopping” for their healthcare online and looking at cost metrics when making their decisions.
- Systems should provide upfront estimates of costs and detailed end-of-care financial statements.
- The other component of transparent care is quality. Health networks need to make their quality
metrics readily available. This includes patient outcomes, patient satisfaction scores, physician reviews, etc.
- All Medicare and Medicaid data is already made public. Systems should have this data easily accessible for all patients and providers within their network.
- The other component of transparent care is quality. Health networks need to make their quality
- Ease of use and timely access are crucial aspects of the patient experience. Within a health system, it is critical that a patient be able to receive all medical care easily and in a timely manner.
- Having large waiting times for appointments or procedures within a network is a surefire way to get patients to go out-of-network for their care.
Before the issue of leakage can be addressed, it needs to be visualized.
Why is it happening?
Where are patients going?
These questions can only be answered through the tracking of provider referrals. Organizations can only start to accept and manage patient leakage when they are able to see it with their own eyes.
Here at ReferralMD, we offer solutions to help streamline and standardize the referral process and help manage in-network referrals and reduce patient referral leakage.
Our new competitor report feature gives you visibility into referral trends, specifically where providers in your community or competitors are referring their patients or receiving them from. Utilizing this data set will help health systems grow referral volume that is normally lost.
Request a demo today to learn more about referralMD’s HIPAA-compliant collaboration and communication referral management platform.
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