Understanding physician referral patterns to provide optimal patient care

According to the Medical Group Management Association, losses in excess of $200,000 per employed physician are not uncommon. As healthcare organizations drive toward value-based care, the ability to lessen physician practice losses continues to be progressively more critical as declining payments and detrimental factors within the revenue cycle become more common.

Physician referrals are the life blood of a healthcare organization today. It’s important to understand and build a physician referral strategy such as:

1. Measure and track physician referral patterns and leakage.

2. Calculate the value of referring physician relationships.

3. Identify strategies for physician alignment and relationship management.

Measure performance

Tracking the physician referral patterns and leakage is critical. By measuring the performance, there is more insight into metrics, trends, benchmarks and budgets. This will help in improving performance by deciding on changes that need to be made, how to implement the change, who’s responsible, when it will get done and if it actually worked. Communicating the performance to the right people so that the right information is communicated at the right time is crucial.

To analyze the physician referral patterns and performance there are three primary data sets that are helpful:

1. Market claims data; this data usually comes from one of three sources:

  • Risk based payor contracts
  • Purchased health information technology/overall technologies
  • Organization’s own health plan

2. Internal data

  • Patient tracking
  • Value stream mapping

3. Combination of both market and internal

Many organizations do not have access to good claims data, however that does not need to prevent them from performing helpful analysis with their own data.

Patient tracking analytics

One way to make patient tracking easier is by changing data models and reporting to a patient centric model. This will pay big dividends for the revenue cycle success of your healthcare organization by:

1. Consolidating inpatient, outpatient and physician data sets.

2. Assigning a unique identifier to each patient across all inpatient, outpatient and physician services. (MPI)

3. Determining entry point of initial visit (i.e. the first time a patient is seen by an employed family practice physician).

4. Time sequencing every patient visit based on entry point.

  • The entry point for the patient becomes the initial visit.
  • All visits prior to the entry point are grouped as prior visits.
  • All visits after the entry point are grouped as downstream visits.

5. Determining the downstream time period (i.e. 60 days after initial visit).

6. Calculating the downstream visits, gross charges, net revenue generated after the initial visit.

Relationship management

Relationship management should be used in conjunction with all other strategies such as:

  • Survey referring providers
  • Understanding what the physician is doing well and how they can do better
  • Use customer relationship tools (CRM) and monitor patient satisfaction
  • Treat referring providers as customers and partners

Hospitals and healthcare organizations can and need to understand referrals into their patient solution offerings and revenue cycle model. All hospitals can provide actionable information on this through data they already have internally. However, data and reporting are just the beginning. As referring relationships are measured and understood actions need to be undertaken to secure and enhance those relationships. Those relationships are influenced by contracts, personal interactions, culture, as well as clinical outcomes throughout the continuum of care.

Learn more about how your hospital or healthcare organization can use nThrive Analytics to refine physician activity and referral patterns to provide quality care while improving revenue cycle management success. Contact nThrive


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