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Jody reduced out-of-network referrals by five-percent*

March 15, 2016
Jody works for the chief medical officer in a health system comprised of 3 hospitals, 25 primary care practices, and 37 specialty practices of varying sizes.
President and CEO

Throughout this year, I’ve been writing about the people at the heart of healthcare transformation. People like Val, who used Geneia’s Theon® platform to trim claims costs by two percent while simultaneously improving the health of her three million members.

Today I want to tell you about Jody. She works for the chief medical officer of a health system. Her health system is comprised of three hospitals, 25 primary care practices, and 37 specialty practices of varying sizes. Many of the physician practices were acquired in the past five years.

Jody’s health system participates in two accountable care organizations (ACOs): one for its Medicare population and one for a large percentage of its commercial patients. They also have a number of value-based contracts with commercial payers.

A few years ago, the entire health system converted to the same EHR (electronic health record). As they acquire new physician practices, the health system has been transitioning them to the EHR as well. The implementation and subsequent use of the EHR had gone smoothly; however, significant gaps still existed.  

The health system found that the EHR captured all of the activity within its network, but it continued to be blind to all of the clinical events occurring outside of the organization. In addition, the health system wanted a solution that takes in data from all sources – claims, clinical, patient, physician, pharmacy, labs, clinical wearables, and more – and then applies one set of rules to make the data meaningful and actionable. Ultimately, Jody’s health system determined that it needed a 360-degree, real-time view of each patient. And perhaps most importantly, it wanted a multi-payer platform so that all ACOs and value-based contracts could be managed the same way.

That’s why Jody’s health system chose the Theon® platform.

During implementation, the health system’s chief medical officer determined and articulated her goals for the first year. She tasked Jody with designing initiatives that would help the health system quickly recoup its investment in the advanced analytics solution. 

Jody used the Theon® platform to determine the ‘low-hanging fruit,’ and within five minutes, she identified a severe leakage problem.  Next, she used the application to view the overall picture of care being provided to her patients. She quickly determined that a large percentage of her patients’ care was delivered out of the health system network. Then she drilled down into the information to look more closely at leakage in specialty care, labs and x-ray, emergency department, and inpatient visits as well as the referral patterns of the affiliated physicians.

Jody’s analysis within the Theon® tool yielded two sources of leakage she wanted to remedy in the first year:

  1. The out-of-network referral rate for a large, recently-acquired primary care practice was twice the rate of its peers. Jody launched a comprehensive physician and patient education program as well as a new incentive for in-network referrals. Within 12 months, the practice’s referral rate had decreased significantly, to just above the peer average. Jody’s leakage initiative not only increased the system’s revenues but also improved its shared savings from ACO contracts as a result of this practice more efficiently meeting quality measures.

  2. Of all the services being delivered out of network, gastroenterology – with more than $1 million in out-of-network referrals in two years prior to implementing the Theon® platform – was by far most frequent. Upon further review, Jody determined that the health system had only one in-network gastroenterology practice, and it was not taking new patients. The health system subsequently added additional staff to the practice, and within six months, these in-network gastroenterologists were meeting more than 70 percent of the demand.

Together, these two initiatives resulted in a five-percent reduction in out-of-network referrals at Jody’s health system. They also improved the care coordination for the associated patients – the men and women whose primary care physicians were in the newly-acquired practice and those in need of gastroenterology services.  Another example of how our technology with a heart is helping to transform healthcare.

*Jody’s experience is an illustrative example based upon the actual experience of a Geneia client. This information is provided for illustrative purposes only. Jody is fictional and not intended to represent any specific person. Any direct similarities to any real person are purely coincidental and unintentional.