----Lead Forensics----

Luke Wylie

Data Scientist

Re-Imagining Care Networks

Can you imagine not knowing how a customer came to be a customer?

In many ways, this is the problem hospitals have faced for many years. Hospitals relied on the referring physician to be loyal to their facility and in return, refer patients to them. But consumers have choices, insurance plans steer to the low-cost setting, and physicians now do more procedures in their offices. How do today's hospitals have a co-operative (collaborative and competitive) relationship with its very lifeline to the patient?

The provision of care is taking on a life of its own.

Traditionally, providers were focused on driving patient volume to the hospital by working directly with physicians. They used any and all legal measures to attract and retain physicians to their Medical Staff like preferred parking spots, operating room slots, food in the physician lounge, space in on-campus medical office buildings, etc. When necessary, providers have used additional financial strategies to attract physicians to practice medicine at their hospital including the purchasing their practices as well as an outright employment to bond the physician and the hospital.

Usually, the attempt to understand the inherent consumer selection process involves examining demographics, health status, and existing healthcare infrastructure. Today, there is an evolving care network science, which has proven to be a better way to understand how local community care networks evolved and where they are heading. This science studies the providers who deliver care in the community. A critical component of this endeavor is understanding referral patterns around local primary care physicians, specialists, lab, radiology, skilled nursing facilities, home health, hospice, and hospital systems. New tools like the Perception Health platform TEAM help the network of providers understand, analyze, and visualize the complex referral relationships that exist in every community. This deep understanding of a local market empowers providers to deliver a more efficient and effective product to their community.

While referral patterns primarily help us understand a patient’s journey through the healthcare system, they also shine a light on a physician’s preference for specialists and a specialist’s preferred place to deliver care. Today’s executive needs to be able to visualize vast amounts of information in one graphic. This view of the pre- and post-acute care business helps the quarterback of the community care network understand where the best treatment options exist based on access, quality, and cost. These patterns allow care managers to engage providers about their referral patterns and ask the most important behavioral health question: Why are you doing this?

Once you discover the reasons for “leakage” outside of your network, the next logical step is to quantify a dollar amount being lost due to this pattern of behavior.

This process is accomplished by investigating a physician’s typical charges and collections and extrapolating these values out to their leaked cases. For example, it may be prudent to investigate an acquisition strategy or investment in new technologies or infrastructure if your network is losing millions of dollars in potential revenue due to doctors’ referrals patterns.

Another way to increase efficiency is to understand your physician’s coding habits. Comparing a physician’s distribution of CPT codes to national averages in their specialty provides insight on whether a physician is under-coding and losing potential revenue or over-coding and risking potential investigation.

Making sense of large amounts of complex data is a task every healthcare organization struggles with today. It is paramount to analyze these relationships and provide visual representation in a way that promotes clarity, which suggests a strategy and creates a clear path to execution.

*Originally published by HIMSS – Tennessee Chapter (TN HIMSS Newsletter May 2015)