Retention of existing patients is one of the most important and cost-effective tactics a health system can employ to increase revenue and promote growth. To mitigate outmigration, it’s important to understand the two key types of outmigration, establish best practices for assessing outmigration, and identify opportunities to increase retention.
There are two primary types of patient outmigration:
- When a patient within your service area leaves the area for care
- When a patient goes outside of your provider network for care, either through a self-directed or provider-directed pathway
Establishing and reviewing network integrity and patient outmigration reports on a regular basis will highlight actionable growth opportunities and provide you with a framework to develop corrective action. This post offers some suggestions for examining patient outmigration.
Identify All Relevant Data Sources
Internal sources of data, such as electronic health records (EHRs) and practice management tools, can contain some information about where providers are sending patients. Even with specific out-of-network referral workflows built into the tools, it’s not enough to fully understand outmigration. External data is required to understand the frequency and trend of patients receiving care with a provider or at a facility that is not part of your network.
To fully understand the patient journey, choose a healthcare analytics partner with the most complete all-market, all-payer data. You can gain insights into where patients are going for care and patient movements across facilities and between providers for specific procedures and diagnoses. This holistic view will give you the ability to clearly demonstrate the flow of in and out of network care pathways.
With a more complete picture of your market, you will have answers to key questions like:
- How many patients are leaving the area for care, where are they going and in which service lines?
- What are these patients’ demographic characteristics?
- Which tertiary and quaternary care hospitals are attracting patients for subspecialty care?
- Which health systems and providers are receiving the most net-new patients and from whom?
- Who are the performing providers, and how often does an established patient leave the network for care by an out-of-network provider?
- What is the potential for revenue recapture?
- What is the benchmark for outmigration?
Add Relevant Context
Your organization’s ability to develop a strategy for reducing outmigration depends on consistent, repeatable, detailed, accurate and timely analysis. Therefore, network integrity reports should always assess and take into account the following factors:
Service Area. Your organization should have well-defined service areas based on patient origin. Typically, this consists of a primary and secondary service area. Primary service areas (PSA) include contiguous geographies (county, ZIP 3, or ZIP 5) with 75–90% of health system volume by patient origin. Secondary service areas (SSA) account for or build up to 90–95%. Service areas provide important context around where the majority of your patients come from, which defines your addressable market and also contains context about what’s outside your market. As organizations grow and expand, service areas can change, so be sure to review the definitions frequently and make adjustments as needed. Your analytics solutions should have the flexibility to not only report on PSA/SSA, but should give you the flexibility to configure custom market areas as needed.
Network Status. Healthcare facilities, such as hospitals and ambulatory surgery centers, as well as physicians and other care providers, should be consistently and accurately classified across your market as either in network or out of network. There are also sub-designations of in- and out-of-network providers, such as employed, affiliated and aligned. For facilities, sub-designations include owned, joint venture and partnership. Every healthcare organization defines these categories slightly differently, so be sure that your external data partners are robust enough to handle these complexities.
Service Line Taxonomy. In order to take action, it’s necessary to understand where outmigration is occurring from a clinical perspective. Most healthcare organizations use service line groups to segment procedures into business lines that assess cost and quality. When applied appropriately, service lines can help identify where subspecialty and surgical care is leaving your network.
Revenue Benchmarks. How will your organization measure the financial impact of outmigration? There are many metrics that can be used—net revenue, income, contribution margin, operating margin, EBITDA or a combination of these measures. Having this information readily available to append to your network integrity reporting will help quantify relative impact and prioritize outmigration mitigation efforts.
Patient outmigration can be caused by a number of factors. Regular reports should be consistent, have well understood metrics, and highlight critical opportunities. When interpreting the insights, It’s also important to apply local market context to identify what actions can or should be taken.
Physician-directed care. Physicians and other care providers often write referrals for patients who need specialty care. However, the need for a formally documented referral in the EHR is not always necessary, which means it can be difficult to tell when a provider is directing a patient outside of your network for care. Using market claims data can be a good way to understand where strong provider referral relationships exist, even when there is no formal referral connection.
Non-physician influencers. There is a presumption that only physicians influence a patient’s decision on where to receive care. However, there are other clinical and administrative staff who come into contact with patients and can also influence where a patient goes for care. These individuals can include referral coordinators, practice managers, medical assistants and nurses.
Patient choice. Simply put, patients might prefer providers outside of your network for specialty care. Many commercial plans allow for self-referrals, with only a selection of procedures that require prior authorization or a physician order. Patients may leave your network for care due to proximity to home or work, recommendations from family and friends or long-standing provider ties.
Availability of services. A primary reason for patients leaving the area for care is availability of services. There are two features of availability: whether the service is provided at all, and the timeliness of getting an appointment. If specialty care is needed, patients often cannot or will not wait too long before seeking care. Sub-specialty services, such as certain types of transplants or cancer care, may only be available out of state.
Gaining insight from outmigration reports will help you identify patterns and trends over time, as well as establish key performance indicators (KPIs) for tracking improvements.
Specific actions to retain patients include:
Provider directory. Maintain and support an updated provider directory with descriptions of subspecialties for doctors in your network. Start by sorting the providers alphabetically or by general specialty and then work with senior leadership at your provider organization or health system to further categorize providers. Make this directory accessible by adding it to the EHRs used by the healthcare professionals initiating referrals.
Provider outreach. Take an individualized approach with physicians who may have an opportunity to retain patients in network. Start by informing them of the precise services your healthcare system offers and engage them in dialogue around quality and service offerings. Refrain from assuming that the provider is actively referring patients out of network.
Service line investment. If patients often leave the area for care in a specific service line, or if the trend is rapidly increasing, consider investing in that service line. When a patient stays in network for care, their care is better coordinated and is typically closer to their residence. Additionally, these advantages may increase patient satisfaction.
Access to care. Your patients will be more likely to remain in network if you make it simpler for them to plan appointments in network than out of network. Help patients make their follow-up appointments at the time of the referral, and offer online and digital appointment options.
Want to learn more?
Populi can help you gain a better understanding of outmigration in your own network. Please contact us to schedule time to discuss your needs.