This is a post by Dr. Tim Crowley, Vice President of Physician Network Services at Kyruus.
Imagine you are a King in Medieval times, and your fortress is under siege by an invading force. You have planned for this by building up more provisions of food and water for your people than your opponent could possibly bring to the battle. As the height of the siege, you make a both terrifying and mystifying discovery: Your own people are sending food and water out to your enemy!
This is the situation many hospital CEOs face every day when they review data revealing their own physicians-- for whom they provide enormous "support" (read subsidies to cover losses), and whose very own paycheck depends on the revenues that specific system was expecting their patients to generate-- are referring out of network. This is leakage in its purest form.
So how do you manage this problem?
The first thing you need is data, something most systems possess (in varying degrees of accuracy and "actionability"). It can be gathered and tracked internally, acquired from payers, data vendors and some cases, directly from the states that monitor and sell Physician identified data (see accompanying list).
Once you’ve determined who is leaking, what they are leaking and where they are leaking to, the next task is to determine WHY these physicians are referring cases out of the system. Then, and only then, can the strategy for dealing with this incredibly exasperating problem be formulated and implemented.
Figuring out the “WHY” requires one-on-one, practice-by-practice, or direct meetings with small groups or "Physician Pods,” to ask why physicians are referring out of network.
Warning: This question needs to be posed in the right way so you don’t make the problem worse. Also, the answers to this question may be quite humbling…
Remember, this is not a time to investigate, castigate, regulate or humiliate. It is an opportunity to ENGAGE with your physician staff, to LEARN about your system and find out why they refer patients away from your facilities and specialists.
The answer(s) to the “why” will become immediately (if not painfully) clear. They may include:
1. Ignorance of services that you currently provide and assumed ALL knew about.
2. Ignorance of specialists who are on staff who provide services you assumed ALL knew about.
3. Ignorance of the quality and better outcomes of the services you provide and assumed ALL knew about
The current generation of Primary Care Physicians, who now or at some time in the past made rounds on their inpatients before hospitalists came along, knew SOMETHING about your hospital and your specialists. However, as this generation approaches retirement, replaced by the new generation of PCP's (who never darken your door), this problem will only get worse.
Unless you ACTIVELY PROMOTE, INTRODUCE and EDUCATE your referring physicians about the services and specialists in your market, THEY WILL HAVE NO WAY OF KNOWING WHAT YOU CAN DO FOR THEM AND THEIR PATIENTS. (IF IT SOUNDS LIKE I AM SCREAMING, IT IS BECAUSE I AM!)