Helping ACOs Move Beyond Network Leakage – More Than Just Numbers

Helping ACOs Move Beyond Network Leakage

For years, network leakage has been a hot topic for ACOs, with significant implications for a number of areas including revenue, quality, patient satisfaction and more. Successful ACOs understand that when it comes to network leakage, it’s important to focus on more than just the numbers (total number, %, etc.). It is equally important to look beyond the numbers and tease out the implications for effective network management. These ACOs must commit to understanding the causes of network leakage and to addressing the underlying issues.

We have worked closely with our customers, using the reporting functionality within PH Exchange, our referral management platform, to help them better understand their network leakage and the reasons behind it. With PH Exchange, they can analyze comparative data across all practices and specialties. They can also measure movement in data across weeks, months and years. They can then compare that real-time data to their claims data, which typically lags by 3 months.

Here are a few examples of patterns and potential issues we have helped our ACO customers identify, and how they can work toward solving them:

Education Gaps

Tracking leakage by practice and physician helps ACOs identify educational opportunities for specific practices.  It turns out that many physicians didn’t even realize that referrals were going out-of-network until it was brought to their attention. Educating these physicians on who the other ACO providers are, and why it is important to refer to in-network physicians is key to impacting network leakage.

Specialty Gaps

It’s possible that referring providers are simply not fully aware of the capabilities available in their own network (i.e. don’t know that the Urology group has a fellowship-trained provider in female pelvic floor issues). Analyzing data and patterns can help ACOs and practices identify potential gaps, and may indicate that it’s time to recruit a provider trained in those specific capabilities (i.e. female pelvic floor issues).

Geographic Gaps

Analyzing data from a geographical standpoint can help ACOs see where the referrals are leaking out, and may indicate a need to add more providers in a certain area of town.

Patient Requests

Sometimes, network leakage occurs because a patient simply requested a referral to an out-of-network provider.  This could tie back to geographical limitations or could even indicate a customer service issue on the part of an in-network practice.

It is important to understand why network leakage is happening, and what you can do to address it. It is equally important to understand that not all network leakage is bad.   While sending a patient out-of-network to an expensive academic provider will likely end up costing more for care, there may be times when it makes sense to send ‘out-of-network’ referrals to hospitals or providers that are less expensive than those in-network.

All About The Data 

Moving beyond just the network leakage numbers requires a robust referral management system that allows extensive reporting on referral patterns (including reasons for out-of-network referral) and the ability to drill down, to uncover specific situations and allow network managers to respond appropriately.