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Surviving CMS “Crackdowns” on Medicare Advantage (and similar) Plans

By: Vytas Kisielius, CEO, ReferWell. January 4, 2018.
White House greenlights CMS’ crackdown on Medicare Advantage plans

A Modern Healthcare article today highlights the importance for MA plans to do a better job of managing their provider networks in terms of maintaining accurate directory information and ensuring availability for Medicare patients they’re covering (see the full article).

A properly organized and managed referral management system (like ReferWell’s, for example) provides not only significant savings on the total cost of care (on the order of $20-25 PMPM, according to numerous studies) but it also provides “soft dollar” benefits that may be equally significant:

  1. Because we are continuously updating providers’ location and contact information (as they update the system to make sure patients show up at the right place for each appointment), users have the logging and reporting to show that immediately.
  2. Because users can see the full information on all referrals (including attempted referrals that didn’t find a doctor) and their status, those users have real-time information on provider availability, response times to get appointments, and provider responsiveness in closing the loop across their network (including any ‘narrower network’ they create within the overall provider network).
  3. Based on the real-time information, users can proactively address any gaps they are seeing before a reviewer points them out, shortening the review (saving loads of staff time today spent researching these questions manually) and saving money on outside “secret shopper” campaigns and improving the results: a one-star improvement is estimated to be worth $40 Million in increased reimbursement from CMS, according to an executive at one MA plan!

So, in addition to all the other financial benefits, using an automated referral management system positions users to take on these types of reviews in the future and passing them with flying colors!


Conversation With Dr. Jeff Sachs Of Sachs Policy Group.

By: Vytas Kisielius, CEO, ReferWell. December 2, 2016.

Dr. Jeffrey Sachs has been a pioneer in health care reform and system transformation for over three decades. He was one of the key architects of New York’s Medicaid Redesign Team process and the Global Medicaid Cap. He provided key guidance to the State of California in the development of its 1115 Medicaid waiver in 2010, which created the first DSRIP program in the United States and provided for $10 billion in new federal funding in California. Dr. Sachs founded Sachs Policy Group to advise organizations across the health care industry on how to adapt and thrive in a changing policy and market landscape. He has advised hospitals, health systems, health plans, behavioral health organizations, technology companies, long term care organizations, unions and others.

We were fortunate enough to sit down recently with Dr. Jeff Sachs, founder and head of the Sachs Policy Group, to explore some of his views on the evolution of value-based care and the central role of referral management in that evolution. Here are some excerpts from that conversation:

Q: For quite some time, you have been a strong advocate for switching to value-based, versus fee-based, healthcare delivery models in order to improve overall health outcomes. What are the key drivers that formed your view?

You really do get what you pay for, and I saw going back to the 1980s that if you pay for volume and complexity, but not quality or outcomes, then the system is going to deliver volume and complexity but do a much less consistent job at delivering better quality and outcomes. That observation has only been reinforced over the years, and so has my belief that the delivery system needs transformative change in order to orient itself to delivering better health with the needs of the patient at the center. It’s hard to do, because health care does not naturally lend itself to being consumer-driven in the way that media or technology are. Technology itself is actually an essential mechanism in changing the delivery system to make it more consumer-centric and focused on value. I think the pressures and possibilities created by new technologies to coordinate care, share information and guide better work flows are even stronger drivers of change than government policy at this point. Especially now, with policy so much in flux with the recent election, and a Republican administration likely to increasingly turn to the market for solutions to problems.

Q: You have said that referral management is one of the linchpins of successfully implementing a value-based care scheme. Can you elaborate why this is so?

Three important obstacles that tie into the referral process hold us back from achieving true value-based care: 1) the referring provider has little insight into the optimal specialists to whom to refer a specific patient, from a value-based point of view; 2) the referring provider and the specialist have little control over how each other delivers the care to each specific patient, given the difficulty and inefficiency of coordinating care across organizations and platforms, and patient availability; and 3) all providers lack sufficient visibility into “how it’s going right now” in order to modify their approach and the choices they make each day. These obstacles can be overcome with a comprehensive referral management capability that is fed by quality-of-outcomes data, incorporates evidence-based guidelines where appropriate in the early stages of the transition between providers (aka a referral), and which simplifies care coordination and data transparency. Such systems exist already, they just haven’t yet been embraced and deployed for what they could do – but the potential is massive.

Q: Many people have said that better referral management is achievable now, due to the emergence of recent technological innovations. What improvements are you seeing networks deploy and how is that affecting the quality of care?

There are several firms offering referral management capabilities that go beyond the clinical data sharing schemes currently being pushed by all the EMR vendors. The entire decision as to who to refer to, when the patient and their primary doctor arrive at that decision, and how to coordinate the care as it’s being given by both PCPs and specialists is not even part of the remit of an EMR system. Once that decision is made, and the clinical data associated with the patient being referred is ready to be transferred, there are any number of ways to accomplish that task – including HIEs, Direct Trust, or real-time exchange through one of the cloud-based referral platforms like ReferWell&tm;.

What we’re seeing is that some networks are recognizing the distinction between referral management on the one hand, and clinical data sharing on the other. By separating those processes and focusing first on managing the referral decision-making tasks more efficiently and effectively, these networks are finding that they can make a significant impact on the cost and quality of care resulting from referrals. With those improvements in place – including the ability to make scheduled appointment times available to the PCP and their patient at the point of care, sharing insurance coverage information so the patient can avoid showing up at a specialist who doesn’t take their insurance, etc. -- they can then decide exactly how best to make sure the patient’s clinical information arrives from the primary doctor to the specialist. Here again, we’re seeing some innovations in allowing real-time communications between providers on different EMRs that operate much like a Facebook wall, so it’s intuitive and easy to use, but HIPAA-secure and limited to only that patient/doctor combination. All of these exciting innovations are moving the quality of care ahead in ways big and small, from improving patients’ experience and rate of compliance to facilitating comprehensive and continuous coordination of care between otherwise unconnected doctors, clinics, imaging centers, physical/occupation/behavioral therapists, and home care providers.

Q: You said recently at the CHCANYS conference that digital health technology would accelerate the movement toward comprehensive care coordination and value-based care delivery. Are there any advances in particular that you find promising?

The next generation of telehealth technologies is very promising and I think moving in the right direction to be fully and thoughtfully integrated with the delivery of care. For example, one solution available for nursing facilities provides on-call physician services at the bedside via video with specially designed devices that let the remote physician view and hear the patient’s symptoms in some ways even better than a typical physician at the bedside. Nurses who need physician support after hours can get it, which provides relief to them and prevents unnecessary hospital admissions. Portable technology is also helping to transform the delivery of care in one of the most neglected areas: home care. And of course, technology is improving the ability to keep care within a coordinated, value-aligned network through referrals for medication, specialist care, post-acute care and other major cost-driving areas.

Q: What are the major obstacles to the adoption of value-based care in New York, and in the country at large?

The inertial force provided by culture is not to be underestimated! It’s hard to change mindsets that have built up over decades and been enshrined in institutions, work flows and attitudes. But beyond that, the period of transition between FFS and value-based care (particularly the more meaningful models that include financial risk for underperformance) is hard because every provider making the transition has a foot in two canoes that are pulling in opposite directions. It’s not an easy place to stand, and we don’t get anywhere by just standing still, so I’m always looking for ways that we can responsibly accelerate the transition to value to remove conflicting incentives, while making sure that providers are positioned to succeed in the new world. This successful positioning can mean many things: culture change of course, but also forging new partnerships and ways of using information across organizations.

Q: Thank you so much for your time, it has been a pleasure speaking with you.

Thank you, it was great talking with you too. And we barely even mentioned the election!


What’s In A Name??

By: Vytas Kisielius, CEO, ReferWell. March 30, 2016.

We recently made a change that we feel is significant, for more than just symbolic purposes: we changed our company’s name from Urgent Consult to ReferWell.

Here’s our new logo:

Responsive image

We believe it’s important that you know what we’re about, which is to help you improve and streamline the broken and inefficient referral process that prevails in our industry today.

When we say we want to help you to refer well, we mean it across a number of dimensions:

  • First, the administrative process itself, which today involves more phone and fax time (up to 10 minutes per referral) than is necessary. With ReferWell, the process is complete in under 3 minutes – adding up to a savings of 2 hours per day, based on the average office’s daily referral volume!
  • Second, the patient experience, which today involves their being tasked with finding, confirming insurance coverage, and then scheduling an appointment with the right doctor. All told, that hassle contributes to the finding that nearly half of all referrals never get followed through as a visit. With ReferWell’s ability to schedule the specialist appointment at the point of care, we’ve cut the no-show rate to as low as 10% -- which represents a more than 50% increase in the volume of visits making it to specialists’ offices!
  • Third, the sad reality is that patient clinical information including the actual reason for the referral rarely gets to the specialist, and the consult report gets back to the referring physician even less often. This results in wasted time at the specialist office at best, and at worst, crucial diagnostic insights are not being shared nor getting back into the patient’s comprehensive medical record at their primary doctor. ReferWell enables both the referring and consulting physician to share notes and reports simply and painlessly, regardless of the EMR system each is using, leading to better coordination of care and outcomes for patients.
  • Finally, the fact that referrals happen all the time but are essentially an ad hoc process means that few providers get good analytical insight into the referral patterns and practices that could be improved. ReferWell fixes that, with comprehensive reporting and analytical tools that allow providers to get a better handle on what is going on, who is collaborating more responsively and fully, and ways to improve the patient care by directing referrals more intentionally.

It all adds up to greater well-ness: more efficient administrative handling, better patient compliance, increased coordination of care and timelier insights into how to continually improve the process of helping patients get well better and faster.


Can We Talk?

By: Amish Shah, MD, MPH, ReferWell. January 4, 2015.
Health care industry has a message for EMR developers: “We need to talk.”

The last decade has seen the rapid adoption of the electronic medical record (EMR). While a few major EMR software companies have become familiar names, the overall market is very fragmented, with a dizzying array of products available for almost every type of practice, budget and clinical need. But the health care industry has a message for EMR developers: “We need to talk.”

While each EMR features proprietary features and a unique user interface, there is almost never a way to share information across EMRs. Since they were never designed to talk to each other, clinicians have been left with a busy signal when networks form, entities merge, or information must be shared for patient or provider benefit.

Several industry leaders and the federal government recognize the problem. West Health Group CEO Nicholas Valeriani writes “The current lack of interoperability within clinical information systems results in needless delay, duplication, error, and preventable patient harms… [It] frustrates the coordination of care that is essential to having optimal, patient-centered healthcare.” The American Hospital Association, American Medical Group Association and Electronic Health Record Association echoed these sentiments in letters to Congress.

Karen DeSalvo, MD, the National Coordinator for Health IT, has stated that interoperability is one of the US government’s top priorities in health care over the next 10 years. Some groups such as HL7 have made significant progress establishing standards by developing a common language. But they face challenges, as EMR developers have different incentives and big stakeholders can’t agree on how those standards should be established, making a short-term solution very unlikely.

Fortunately there is a new solution. ReferWell uses custom integrations and our simple yet robust web-based platform to allow today’s health care network to share information seamlessly across providers and different EMRs. We make it easy to share data, track patients, and keep your network humming with full HIPAA compliance.

If you need to talk, we’re on the other end of the line. Contact us today.


A Referral Is The Building Block Of Your Health Care Network.

By: Amish Shah, MD, MPH, ReferWell. September 9, 2014.

In today’s environment, health care has become increasingly specialized. Primary care physicians (PCPs), once careful to refer patients out in the “gatekeeper” HMO model, have now left these habits behind and come to see themselves as coordinators of care among the patient’s multiple specialists. Part of this is explained by the advancement and complexity of medical science, the desire to improve patient satisfaction, and also avoid medical malpractice. According to a recent article, the referral rate has more than doubled in the last decade, with approximately 10% of outpatient visits leading to a referral.

Given this new paradigm of PCP-coordinated care, how can an Accountable Care Organization or insurance provider hope to maintain satisfaction for their covered individuals while reigning in out-of-network charges? The answer begins with the understanding that the referral is the building block of the network. Without a focus on the targeted referral, a network is simply a group of loose affiliations.

Patients themselves do not often understand who they should see for any particular problem. Most know to call 911 for an emergency, which would lead to an Emergency Department visit. Some would consider going to an Urgent Care center for more minor concerns. If they have an existing provider relationship, some might call their PCP or a specialist directly, especially for chronic problems. A few might call their insurance company or network for guidance. While initiatives targeting the patient to reign in out-of-network usage are possible, they also risk the perception of being obtrusive.

Empty pockets
Patients themselves do not often understand who they should see

However, no matter how the patient makes initial contact with the health care system, what happens next is much more amenable to influence without presenting a burden. Physicians and their staff in the medical system have a much greater ability to steer patients toward a particular network, mostly because they want their patients to get the best possible care. And if that network features close coordination, the referrals keep all downstream care within it. Furthermore, the closer the coordination of care and the greater the ability to keep the patients in-network, the higher the perception of quality!

How does one approach the problem of creating a closer, more efficient network? The first step, as highlighted by many recent writings in health care journals, is to develop an understanding of the referral patterns within a group. Are physicians continuing to send referrals away for reasons such as old habit or poor knowledge of in-network providers? Are they unfamiliar with certain providers and the care that the patient might receive? Are PCPs confident that they can provide their patients resources that will deliver effective, excellent care with convenience? Finally, is there a convenient way to send the referrals and coordinate information?

Technology has the potential to build a strong, close network out of loose affiliations. ReferWell.com has developed a web-based platform to help make referrals and share information among providers fast, easy, and convenient. We keep patients traveling within your network to prevent leakage. Referrals within the network can also be steered toward available or less costly providers, similar to strategies used by early successful ACOs. We give patients confirmed appointments and help avoid test duplication, freeing them from frustration and hassle. We help implement our approach in providers’ offices to make their workflow smoother. Finally, we provide reporting and metrics to help you understand how and why patients are moving through the system, so you can see the financial results and target corrective measures.

The referral is the building block of your provider network. Let us help you make your foundations stronger and more effective.


Sources
  1. Song, Z et al. “Patient Referrals: A Linchpin for Increasing the Value of Care” JAMA 2014, Aug 13; 312(6): 597-8.
  2. Barnett, ML et al. “Trends in physician referrals in the United States, 1999-2009.” Arch Int Med 2012; 172(2):163-170
  3. Mehrotra A et al. “Dropping the baton: specialty referrals in the United States.” Milbank Q. 2011: 89(1):39-68