Healthcare is starting to wake up. More than ever there is an eye toward long-term strategy instead of the typical approach to fix the immediate need with something tactical but not sustainable. This pandemic has caused our industry to think a bit differently, inspiring many to look for improved processes, especially within the world of digital care coordination.
Any change endeavor requires key indicators for measuring the progress toward success. For some reason, digital care coordination more often than not isn’t viewed this way. I am not sure if that’s because the concept of a closed referral loop is so foreign to most or if stakeholders just believe, as I hear often, “we have no time for that.” COVID-19 has forced us to make time for it. Digital care coordination must be top of mind for the benefits to be realized, and we’ve found seven that have the potential to improve clinical outcomes while reducing costs.
Follow Through is the simple measure of the percent of patients that actually attended their scheduled referral. Everything else – No Shows, Cancelations, Send To Patients, or Send to Others (i.e. call center) – is not considered follow through. Each of these dispositions requires a unique intervention that requires contextual analysis in order to truly make a positive difference.
We like to set a goal of 85% follow-through with our clients. Measuring follow-through rates will allow you to improve your source of cancellations and no shows, increase revenue, reduce administrative cost, and improve clinical outcomes.
The obvious measure is access. The shorter the time between visits, the more likely patients will show up. Although Blockit/QliqSOFT customers have an average of 4 days between visits, the national average of time to schedule an appointment is 29 days. That leaves nearly a month for patients to second guess their need for a referral, find a different provider, forget about their appointment, or discover other barriers that stand in the way of follow-through.
Besides access, measuring this metric also provides insights into the overall health and needs of the network. Practices often try to solve the access problem by adding more providers, but a better solution could be decreasing those days between visits.
If your days to visit are seven or fewer, adding more providers creates frustration amongst your providers because you are now diluting the referral volume. Is the answer more providers or is it an improved schedule design within your existing providers?
The four-to-six-minute referral time leads to what I call the death zone, especially in the Urgent Care / Emergency Department where minutes feel like hours no matter if it's a provider or ancillary staff executing the referral. There are obvious time considerations, but this metric also has a direct correlation to adoption and adoption has a very direct correlation to overall success.
When the average time to schedule a referral goes above four minutes it's time for a visit with the referral’s sender. It’s a chance to educate and to evangelize a little bit. Honestly, it’s shocking how many senders don’t even realize this is being measured or that their peers who have implemented a digital care coordination strategy are achieving 2-3 minutes referrals with ease. Watch how referrals are being performed and listen to what the speed bumps may be. More often than not those speed bumps are self-imposed, and a little information and lots of encouragement will improve this metric.
Even if your primary goal is not revenue this metric is still so important because it is a great indicator of so much more. First and foremost, it leads you to ask about the number of patients falling through the cracks and not getting the care they need. There are also patient engagement and patient satisfaction components in this as well.
There are some really great studies and datasets that allow us to roughly compare the overall referral activity to national averages. Blockit and QliqSOFT use these to construct the following standard:
• Primary Care Referrals Sent: 33%
• Ophthalmological: 21%
• Gynecological 18%
• Gastrointestinal 18%
• Orthopedic 16%
• Dermatological 15%
• Cardiovascular 15%
• Specialist Referrals Received: 45% of total patient volume
• Emergency Department Discharges: 69.9% consists of an ambulatory referral.
• Inpatient Discharge: 63% consist of a non-surgical ambulatory visit within 14 days.
• Urgent Care Speciality Referrals: 2500 per location annually.
(See sources below)
This is how many referrals are actually scheduled to completion versus sending it to the patient to finalize or sending to a call center to act on.
This is an important metric because the likelihood of a follow-through increases by 72% when providers book the referrals. That drops by 50% when the responsibility is put upon the patient, and the cost of the referral goes through the roof when it is sent to a call center.
The convenience of sending to a patient and sending to a call center is very attractive, but it has very negative consequences. What I see regularly is the convenience overshadows the importance of the metric and mitigates action. This can’t happen if you want to realize the longer-term outcomes of a care coordination strategy. Doing the referral process right should take no longer than 3 minutes.
What you will almost always find in this measure are user patterns. I hate saying it this way but this is where you have overall detractors that are passive-aggressive in their adoption of your care coordination strategy so they use the tool to essentially pass the buck. The challenge with not confronting this measure is that it tends to be viral and quickly spreads to those that have adopted and suddenly entire locations are not maximizing their capabilities provided to achieve success. This particular metric needs a keen eye, considerable finesse, and most importantly, quick action.
83% of all eligible US hospitals are being penalized for excessive readmission rates. $563 million in Medicare payments are being withheld, and Medicare isn’t the only payer pressuring hospitals to prevent hospital readmissions. AHRQ found that readmissions of privately insured and Medicaid beneficiaries cost $8.1 billion and $7.6 billion, respectively. A well-thought-out digital care coordination strategy can affect HRRP penalties and should be measured to do so.
Anytime a patient goes out of the system it makes it so much harder to get them back in. That patient is now incorporated into a competing system’s care coordination strategy that includes not only getting them (gettage) but keeping them (keepage). The downstream loss could be tremendous.
Digital care coordination tools like Blockit/QliqSOFT offer insights into your referral patterns, helping you identify the “gaps.” If you don’t currently have those insights, it is well worth a focus group session with key provider stakeholders that results in a successful network redesign.
Different markets will have different needs, and some are even seasonal in nature. The goal is to understand your market demographics and minimize care gaps in order to achieve your overall care coordination goals.
One way to do this is by diversifying your provider network. Below are the 10 physician specialties that generated the highest average annual net revenue for hospitals for those specialties, according to the Merritt Hawkins 2019 Physician Inpatient/Outpatient Revenue Survey. These specialties are must-haves in your referral network due to the revenue potential and they help fill in high-demand care gaps.
1. Cardiovascular surgery: Average revenue: $3.7 million
2. Cardiology (invasive): Average revenue: $3.48 million
3. Neurosurgery: Average revenue: $3.44 million
4. Orthopedic surgery: Average revenue: $3.29 million
5. Gastroenterology: Average revenue: $2.97 million
6. Hematology/Oncology: Average revenue: $2.86 million
7. General surgery: Average revenue: $2.71 million
8. Internal medicine: Average revenue: $2.68 million
9. Pulmonology: Average revenue: $2.36 million
10. Cardiology (noninvasive) : Average revenue: $2.31 million
Embracing the Change
These are exciting but very challenging times in healthcare and even the thought of additional effort being required to do any more work is very hard to accept. The challenge of doing more no matter the promise for better is not new in healthcare, but it certainly has grown. The encouragement I have to offer is that our studies across our platform clearly show that minimal effort focused on these critical measures always leads to significant improvements in clinical outcomes while reducing administrative effort and overall cost.
Sources
1. Comparison of specialty referral rates in the United Kingdom and the United States: retrospective cohort analysis. Forrest CB, Majeed A, Weiner JP, Carroll K, Bindman AB BMJ. 2002 Aug 17; 325(7360):370-1.
2. Gonzalez ML, Rizzo JA. Physician referrals and the medical market place. Med Care. 1991;29:1017–1027. [PubMed] [Google Scholar]
3. National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary Tables, tables 1, 4, 14, 24, 25 pdf icon[PDF – 863 KB]
4. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries September 28, 2011 . http://www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf
5. https://www.beckershospitalreview.com/hospital-management-administration/the-downstream-value-of-integrating-urgent-care.html | UCP Urgent Care Survey – December 2015
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