There are two constructs of care networks. One is the network analysis and perspective of a group of clinicians having either a direct or indirect set of relationships that leads to a flow of patients; and then there's the behavioral flow of patients.
In the 1990s, we began following the first construct, thinking that through benefit plan design, there would be a mechanism to influence patient activity - almost in the form of patient steerage. That kind of worked, but really not very well.
People learned to hit their benefit maximums and cross the threshold of deductibles, and then it was fair game - they could go to the doctor wherever they wanted. Too many patients also learned that if they coughed enough and said, "I'm sick, I need to see this super specialist at the Mayo Clinic," they could probably get through. That construct ended up just not making sense.
When managed care's first iteration died, that certainly was the case. Patients ran off and went to see all these different specialists. What the 1990s gave us, however, was the idea of the primary care provider being the center of patient care. Even though gate-keeping didn't work at first, due to perverse incentives, the notion of having a primary-based care model did make sense to all stakeholders.
Fast forward to the 2000s. We were certainly still at sea, but the primary care-centric model took hold. We hadn't gotten very far with figuring out where to take things with primary care and, sadly, primary care still doesn't know how to survive in the new financial ecosystem. But for the most part, the people driving health care figured out that a primary care-centric model was definitely the way to go. Look at the major investments and innovations of the very large insurance companies. Look at our federal government, through Medicare and changes coming soon in Medicaid. Look at the Patient Centered Medical Home. The people driving these efforts know for certain that primary care is, well, primary
Back in the day, patients would go out of network because they could and because they learned how to do it - and physicians had little to no means, or incentive, to keep them in. But along the way, our hospitals and health systems, the big guys and even some of the little guys, figured out how to maximize revenue. Pretty soon, they were all doing oncology, they all had an MRI, they all did hip replacements and they all had a robot for surgery. Moving up the specialty food chain became the fast path to revenue.
Today, the public and commercial plans that are the biggest purchasers of care are thinking, "We built this monster, and it's out of control. We need to grossly change the economics so that the incentive to keep a patient in the network falls to the hospital or the health system." That is a very wonderful breakthrough for all of us. Because now it says to the hospital or health system, "You wanted to build all of these fancy buildings to take care of these patients, and in order to take care of them, they need to come see you and not go across town and see the other guy in the fancier building."
So really, for the first time, we have a hunger on the part of hospital or health system to say, "Yes, we want to be a global center of excellence and bring patients in from all corners of the globe to receive our wonderful specialty care. But, wait a minute! Our primary care base, the patients who are our bread and butter, have to come here, too. We can't have them sneaking out across town." So that becomes very important, and it demands a new way of thinking.
Eliminate the Root Cause of Leakage
Consider that there's a very simple environment: A hospital owns a health plan, or a health system owns a health plan, and they of course want to be that global center of excellence. They want to bring in revenue from all of their competitors across town, even across the country. But they are also managing a population, and more and more will be at risk for managing them. The overlap of patients the health system is at risk for and patients they provide service becomes very important. In health plan and health system-speak it is called a "sweet spot". If you are a CFO, you want that overlap to become bigger and bigger. That's where the aim shifts over the next 5-10 years. We will make sure that first and foremost, we take care of our own - and then we bring in as many others as possible.
Patients don't just wake up one day and say, "OK, I am going to try to go out of my provider network today, just for the heck of it. That's a great idea." Patients will leave a health system provider network and receive care through another covered system when their experience with their current provider network doesn't go well. They will go out of their current provider network when their primary care physician says, "I'm really concerned about you and want you to have a follow up appointment," and scheduling that appointment takes five phone calls, the earliest appointment is two and a half months away, the time of day to get the appointment stinks, it means taking time off work, and on and on.
That doesn't sit well with consumers. In giving patients access to specialty care, we lack some very basic approaches to thinking about how to prioritize patients and say, "This patient needs to come in. This patient is of high value to us. Open a slot right away." Specialists, and primary care providers for that matter, are burdened by any influx of patients. There is this huge demand for their time. The smartest thing they can do is begin to cut back their schedules and cut back their calendars so that slots can be available. Let's make it easier for patients to get specialty care within the network.
Another thing with schedules and calendars: While pretty much nobody wants to work Fridays and weekends and late at night, patients need care during those times. Those times fit patients' schedules. But what ends up happening, and perversely from an operations perspective, is that the distribution of times when patients can receive care often isn't uniform across the days of the week. That's because they're built around clinician preferences, and there's tremendous variability. To say nothing about the real estate and other fixed costs that are only used 25% of the time!
In looking at a given practice big or small, it can be quite surprising that strangely, out of convenience to many of the clinicians, Wednesdays are a great day to work. There may be 40 professionals running around a clinic - nurses, medical assistants, PAs and MDs - because Wednesday just happens to be a day they all agree to be there.
So there ends up being tremendous chaos around scheduling Wednesdays, but on Thursday afternoon, it's a ghost town. There's one doctor, one nurse, two medical assistants, and that's it. And far fewer patients. There are the same number of schedulers, janitors and everyone else except clinicians and patients. The swings can get pretty wild, and they can extend over time. Should it ever be the case that Doctor Smith is able to schedule patients out for several years, but Doctor Jones, her partner, is open for only the next three months?
There is often no sense of standardization regarding what the slots look like. Many administrators are beginning to look at this and address it. But while that may be done within a clinic or a department, it really also needs to be done with a network view.
Maintain Your Network
The questions to ask are, what is the right yield of cardiology appointment slots within our system for the management of 60,000 patients that are now medically at risk of heart failure? What is the yield? What is the volume? And how many cardiologists do we really need to support that group? Should they have appointments on Saturdays and Sundays and evenings as well as "normal times" to meet the needs of their patients? If they are not available at those times, does that lead to further urgent care and ER visits? Does it lead to people perpetually getting care outside the system? Because if they are revenue-cycled into a new emergency department, they are going to go see the cardiologist in that new system. That is how leakage ends up happening.
The new models of reimbursement and the entire spectrum of alternate payment models look at this and say, "You'll build a network and you'll manage it closely, and you'll be held accountable for the performance of that network." The era we have now entered - which is new and very profound and needed - is one in which the hospital or the health system determines that it needs to build and maintain its own narrow network.
And it needs to look across the quality and efficiency performance of clinicians and different partners and organizations on a consistent basis, maybe every 12 months or so.. It needs to consider whether a course correction is required, taking some people off the roster; saying we have goals, we have targets, we have quality initiatives and this group of folks - despite coaching and careful monitoring and a lot of incentives - didn't cut it, and they are no longer going to be a part of the network.
Accelerating through a hard conversation with a group of orthopedists and saying, "I don't think we are going to renew your privileges or contract? Next year" may seem like heresy, because the more of these people the hospital or health system collects, the more services they provide and the more money comes in. But as the rules of reimbursement shift so there are more ways in which reimbursement occurs for the total management of a patient, and not just the acute delivery of a specific procedure, everything needs to be viewed differently.
The challenge at hand for health systems and hospitals is to say for a given population of patients - whether 30,000, 140,000 or 862,000 - what's the right network, and what are the best performance and access standards for different domains? How many rheumatologists are needed to serve that population? How many dermatologists? What access times are required? Should there be appointment slots available on evenings and weekends? Where does "patient convenience" fit in?
The data can reveal all sorts of things about disease burden, needs and prevention, and acute management. But at the end of the day, that has to be wedded to, what is the supply of clinicians we need for this given group of patients? And how do we maintain the right supply? How do we continually look at the data to inform the composure of the network?
It used to be, these are the terms, take it or leave it, and the network got as big as possible. The new terms going forward will be, this is the primary care hub; this is the strength. And we will build this tremendous team of specialists who are available when the hospital or health system and the patients need them.
That's a new model. And it is very much needed for success in the new era of value-based care.
Michael Barbouche is founder and CEO of Forward Health Group, Inc.a population health management company based in Madison, Wisc.