For hospitals and health systems, attracting patients to receive care in their network and keeping them in-network has always been important. However, the concept of keeping patients in-network has become even more important for organizations that take on risk for a patient base, like organizations participating in accountable care models.
"Not having patients leak outside [the network] is important [for ACOs] because otherwise they're going to lose control of how spending is done and how care is provided for those patients," says Matt Fisher, chair of the health law group at the law firm Mirick O'Connell. "It's going to be much harder to meet the shared savings they're going after."
In addition to the financial implications of keeping patients in the ACO network, providing ACO patients with care from ACO-participating providers can also boost the care coordination goals of the ACO.
"If we're not able to limit [leakage], it makes it harder to…manage the entire population to the best of our capabilities," says Reinhold Llerena, MD, medical director of Arlington Heights, Ill.-based Alexian Brothers Accountable Care Organization, a Medicare Shared Savings ACO.
Sharon Rudnick, vice president of outpatient care management at Advocate Health Care in Downers Grove, Ill., agrees. "It can drive a lot of value…if you're able to coordinate care in your own system," she says. Advocate has a commercial ACO contract with Blue Cross Blue Shield of Illinois and also participates in the Medicare Shared Savings Program.
Though keeping ACO patients in the network is important for member organizations, it is anything but easy to achieve. For example, ACOs cannot restrict patient access to out-of-network providers, even though Medicare ACOs are given waivers on Stark Law referral regulations. "The strategies employed by an ACO to optimize care coordination should not impede the ability of a beneficiary to seek care from providers that are not participating in the ACO," the Medicare ACO Final Rule states. Commercial ACOs, meanwhile, must abide by antikickback laws and state regulations regarding physician referrals, Mr. Fisher says.
While it is not an easy feat, there are some steps ACOs can take to keep patients in the network. Here, Dr. Llerena and Ms. Rudnick share how their ACOs tackle the challenge in the competitive Chicagoland market.
Physician education
Educating physicians on who the other ACO providers are and why it is important to refer to in-network physicians is the first part of the equation to limit patient leakage. "The most important thing from an ACO standpoint is to educate providers," Dr. Llerena says. "Continue to form strong relationships with providers." Educating physicians on who the other ACO-participating physicians are can help keep patients in-network during referrals, which is often where patients exit the network.
Additionally, it is important to emphasize that participating providers share in the same quality, experience and cost goals. "[If] a provider shares the goals of the triple aim, that is attractive to other providers in the system," Dr. Llerena explains, which will lead to more patients being referred to in-network physicians.
Patient education
Once the physicians understand the value of care coordination and who is participating in the ACO, the next step in preventing patient leakage is to educate the patient on how coordinated care will benefit them, says Ms. Rudnick. At Advocate, patient education starts wherever the patient enters the network, usually through a primary care physician office visit. "We do a lot of education while they're at their visit. Physicians say things like, 'If you need further care, please call us first,'" she explains.
Additionally, physicians or care coordinators can help patients choose a specialist if specialty care is needed. "[If] we really truly feel we offer the best care for those services, then we need to explain to the patient why it makes sense," says Dr. Llerena.
"A lot of time patients won't know a good specialist, so they value the fact they can use a physician or care manager as someone who can help them figure out what to do next," Ms. Rudnick says. "Patients need help and want that direction."
When both physicians and patients understand the value of care coordination in an ACO, patient leakage is less likely to occur — meaning the ACO will likely be more successful in its journey to achieve the triple aim.