As a solution in the remote care space, one of the common advantages of going remote we often come across is growing or scaling outpatient care. There is interest in growing outpatient care or increasing outpatient revenues. With the shift in attitudes in healthcare and the advent of technology, healthcare executives both from administrative or clinical backgrounds are in a hurry to optimize their current outpatient strategy. There is a lot of advice surrounding outpatient growth. The aim of this post is to elucidate all the different thought currents that exist when it comes to entering the outpatient market and growing it. It applies to the reader who has an outpatient growth strategy in place and just want to make sure they are not missing out on anything. It equally applies to the outpatient novice, who want to see a consolidated view of all the ways to thrive in the outpatient market. Consider this as a primer on outpatient care.
What is Outpatient Care
Outpatient care, also known ambulatory care, is a broad field of medical tests, procedures and services that do not involve an overnight stay at the hospital. It does not have to do anything about the location of care, but rather the duration. Any instance where the patient does not have to spend the night at the hospital is referred to as an outpatient care. You will see ambulatory care and outpatient care used interchangeably on various websites, but they are essentially the same thing.
Why is Outpatient Care Important?
Hospital revenue from outpatient services grew from 30% in 1995 to 47% in 2016. It rose to 48% of all revenues as recently as 2018. As outpatient care is achieving a growth rate of 9%, compared to inpatient’s 6%, it is expected to make further inroads in the total revenue pie of healthcare systems. Numbers aside, healthcare consumerism that backs lower costs and prices, and the shift to value-based care that focuses on outcome rather than volume, are both making outpatient care into the de facto mode of care. Outpatient care is always the cheaper option and they are more accessible as there are more outpatient facilities than inpatient facilities. Anytime there is the chance of lowering costs while improving outcomes, the payors are interested. So to say outpatient care is important is an understatement as it is well on its way to becoming the dominant form of care, both culturally and medically.
How to Increase Outpatient Care?
At first glance, the question of increasing outpatient care seems rather straightforward. Strategize at an enterprise level how you can move away from overnight stays to same day care. Afterall, the distinction between inpatient and outpatient care is not a tough one. But when brainstorming, one gets pulled in so many directions, all of which are affecting the current healthcare landscape. It is no surprise why this is so, as outpatient care now constitutes almost half of all hospital revenues, achieving over 50% rate of growth in the last 25 years! It is a trend that is set to continue with outpatient revenue overtaking inpatient revenue in the next decade. Noticing such an inevitability, everyone is scrambling to put together an outpatient care strategy that will optimize their health system operations and increase outpatient revenue. Such a strategic shift will bear well for the health system not just now, but for the years to come.
When developing an outpatient strategy, the obvious goal that first comes to mind is increasing outpatient visits and the revenue generated from these patients. If you are able to set up your enterprise infra structure and architecture in such a way that is conducive to outpatient care, you will be able to grow this model. On a nation-wide scale, it will grow with or without you, but how much of it you capture will depend on your plan and execution. We intend to shed light on the different areas you must consider when putting together an Outpatient Growth plan. You will see a common theme arising, which is that by understanding the reasons for growth of outpatient care, you will also be able to use that to your advantage.
These should be your focus areas when putting together an outpatient growth strategy:
Take Advantage of Technological Advances
Over the years, there have been technological developments that make it easier to perform surgeries. As a result, patients can be operated on and be discharged on the same day. Minimally invasive surgical procedures make very small incisions on the skin to insert micro tools like HD cameras and lights. It does not involve large cuts that exposes a lot of muscle and tissue as seen with open surgeries. This reduces recovery time, risk of contamination and likelihood for complications developing from the procedure. Since the surgical scar is small, very little or no post-surgery care is needed.
Ensure you have the following outpatient acute care service lines.
Orthopedic surgeries such as knee and hip replacements were always major income earners for hospitals. Now that they can be done in outpatient facilities in a minimally invasive fashion, it is an even bigger revenue stream for hospitals which operate ambulatory surgical centers (ASC).
Minimally invasive spine surgery (MISS) and Laser spine surgery are both different from traditional open back surgeries. They do not involve long incisions in the back, but rather create a small incision for the surgical site and use laser to treat decompression in the spine respectively. Both have faster recovery time and use local anesthesia, which only numbs the area which is operated on. Like orthopedic surgeries, such surgeries can also done in outpatient care settings, in ambulatory surgical centers.
Technological advancements are not just about increasing the quality of surgeries with greater miniaturization and pinpoint solutions that lowers patient discomfort. They are also about making the whole procedure safer. Major heart surgeries such as catheterization, Percutaneous Coronary Intervention (PCI) and stent are increasingly performed in outpatient settings. This is because of change in safety improvements such as use of arterial access, less contrast agent bleeding risks, better anticoagulation options and improved disposable products.
Dropless cataract surgery means that more cataract surgeries can now be performed in outpatient settings. Around 20 million cataract surgeries are performed annually, but the traditional cataract surgeries were always dependent on the patients administering eye drops post-acute care, which if not done correctly can lead to severe complications. With dropless surgery, the medication is directly injected into one’s eyes. In this one case, it is not minimally invasive per se, but over the long term it is a sturdier solution which results in better patient experience.
Short endoscopes with small incisions and advanced robotic aids have meant that thoracoscopic surgeries are performed in ambulatory surgical centres. It is a method to not only treat certain conditions, but to diagnose bigger problems that an X ray might not reveal.
More bariatric surgeries are performed on an outpatient basis. They consist of surgeries on the stomach for weight loss or other obesity related problems. Laparoscopic adjustable gastric band (LAGB) is the most common weight loss surgical procedure. It involves inserting band on the top part of the stomach to make you feel full after eating less good. Such bands or balloons can be removed endoscopically as well.
Understand the Underlying Financial Reasons for The Shift to Outpatient Care
Lower Costs to Payors and Patients
Universally across the world, the three recognized payors of healthcare are commercial health plans or private insurance, govt. Health plans, and private citizens who pay out of their pockets. All three parties are favoring low-cost care settings. Private insurances would of course want to lower their risks and unnecessary utilization, governments would want to maintain fiscal control and avoid overspending, and citizens would naturally favor more cost friendly options for healthcare wherever the cost is passed down to them. Outpatient care is one way to appease cost concerns of all three stakeholders. An average outpatient visit costs $500, compared to the average inpatient visit that costs $22,000.
Increase Revenue by Opting for Value-Based Contracts
Hospitals that are offering more outpatient services are found to have a higher share of revenue from quality and value contracts. These include a capitation model, where one gets a certain amount per patient, bundled payments which lump many services together for one episode of care, or one sided or two sided risk sharing models, where you get to get to keep a percentage of savings dependent on how much risk you take on. All of these payment structures were devised to promote quality over quantity, and outpatient care is one of ways to excel in these revenue models.
When you are providing outpatient care, you are making a bold statement where the episode of care can be short (for acute care), or long (for chronic patients in their homes), but in both cases you are taking accountability for the patient’s outcome. You are not able to hide behind just providing a nightly accommodation and 24/7 care services, because ultimately independence and prevention of escalation where someone would need that type of care are signs of quality. Of course, the inpatient stays aren’t going anywhere, and will be there for those that need it. But with the rising popularity of value-based healthcare, inpatient stays should never be the first priority unless absolutely needed.
Consider Acquisition for Expansion
Consolidation in the healthcare market rank as one of the most important trends by industry experts year after year. Hospitals, private equity firms and insurance are buying up outpatient facilities. The reasons for this are population health, consumerism and expansion of referral networks. Smaller outpatient facilities are also freed of administrative burdens, which is a motivation for them to join the bigger organizations. At the current pace of consolidation, only 50% of current health systems are expected to remain in the next decade. A lot of such consolidation involves large health systems acquiring new hospitals, outpatient facilities and physician’s practices. As the old adage goes, if you can’t beat them join them, in this case acquire them. Entrepreneurs and physicians hold a lot of power in the healthcare landscape because they have the business savvy and clinical expertise to deliver care to pockets of community. As they are smaller in size, they are more nimble and can make healthcare more accessible in their communities better than a large health system or a hospital could. In many cases, the physician and the entrepreneur are the same person, combining their fields of knowledge to steal a slice of market share away from the hospital.
Luckily for the large health systems or hospitals, consolidation is a fact in the industry and they can always acquire those outpatient centers and physician’s practices that provide a high volume of outpatient services. A large number of patients cycle through these facilities give then the rise in demand for outpatient care. Once brought under the network of one or multiple hospitals run by the health system, the revenue generated from the patients is listed in the health system’s accounting books. By enlarging the care network, all the different referral patterns stay within the network. There is a lower risk of the patient doing some testing, or a surgery at a center outside the network, or getting their primary care at a physician’s office that is outside the network.
But increasing network coverage via acquisition is only half the battle. Even after determining the perimeters of your care network, there is still always a risk of patient referral leakage. Patient referral leakage is when the patient opts to leave your network for out-of-network providers. Either they are not happy with the patient experience or they see the lack of access to a certain specialty care. It is important to control patient referral leakage as it is responsible for an estimated $200-$500 million annual loss for the average hospital. Thus, it is ever so important to build strategic relationships with specialist physicians who are part of your network and have a solid communication strategy of your system’s array of expertise, so patients do not get lured away by other health systems. It should be an organizational decree to prevent network leakage. Ensure that there are fewer referrals and orders from employed physicians to non-employed physicians or competing imaging services.
What type of outpatient facilities are out there in the market for you to buy? Let’s take a look.
You can expand your operations by coming to an agreement with the following sites of care, all of which are outpatient.
Imaging Service Facilities- X-Rays, MRIs, CT Scans, and ultrasounds
These outpatient facilities provide diagnostic and screening services to get a better assessment of the patient.
Specialized Outpatient Clinics
In our society today, where mental health and substance abuse are major problems, there are specialized outpatient clinics that provide psychiatric counselling and cognitive/behavioral therapy. These are like drug and alcohol outpatient rehab centers. There are also other specialized outpatient clinics specifically for certain population segments like children or the geriatric population, or for certain disease areas such as dialysis centers, cancer centers and heart centers.
Ambulatory Surgery Center (ASC)
Same day surgeries are performed in these outpatient facilities.
Urgent Care Center
Patients who require after hours care may walk into these outpatient facilities for serious non life threatening issues such as cold, fever or infections. Some of the more advanced urgent care centers may even be equipped to deal with lacerations of the skin and fracture of the bones.
Primary Care Clinics
Primary Care Clinics are manned by primary care physicians or general practitioners who serve as the initial point of contact for people and their families. Whilst the younger crowd may opt for retail clinics, more legitimate concerns are usually discussed on a consultation with a primary care physician.
These outpatient facilities are the most commercial of any other facilities. One can walk into a retail clinic without an appointment for concerns such as cold, allergies and headaches. Some retail clinics also provide vaccinations and physical exams.
Community Health Clinics
Community Health Clinics care to the socioeconomically disadvantaged in the society.
Ensure Provider Alignment
For the first time ever, more than half of the physicians in USA are employed by a healthcare system and do not own their own practices. As more physicians are joining health systems, it is important to have a solid provider alignment strategy. One needs to ensure high volume of patients are referred by physicians to other employed specialists and sub-specialists. Physicians hold all the power when it comes to determining the course of action for patient. They order outpatient services including diagnostic, therapy and ambulatory surgery. Other than ED visits, nearly all health system revenue originates in the community from referrals, orders and transfers.
As they play such an important role in the coordination of care for patients, healthcare organizations need to make sure that there is proper alignment There are so many things that you can do in trying to design compensation and workload models to improve the physician experience.
The growth and success of your outpatient program will largely dependent on how the quality and efficiency of your physicians. You need to work with them too ensure that all orders are converted to increase payment collection and that lost or unfulfilled orders are eliminated. There needs to be a system in place to follow up with patients to reduce appointment no show rates. As long as the healthcare organizations and their physicians are aligned on the same deliverables and activities needed to meet them, there should be no problem. It is important to develop a clinical administrative structure to complement the management administrative structure. Read these 6 high level physician alignment strategies so that you and the physicians can a cohesive unit.
Ensure Patient Retention
Apart from reducing patient referral leakage and getting a larger chunk of outpatient services, there is another advantage to expanding your healthcare network by acquiring all of the above outpatient facilities. It is patient retention. 12-15% of patients represent 55-70% of all appointments. The customer lifetime value of such patients make a big difference, especially as it costs 7 times more to acquire a new patient then retaining an existing patient. By setting up such a large network of outpatient facilities, a health system increases the chances of the patient staying within its network for the duration of their lifetime. Of course, there are many other factors that come into play when it comes to the science of patient retention. Read these 34 ways on how to increase patient retention through higher patient satisfaction. But one of the best ways for sure is to spread your outpatient wings so the patient has unparalleled access under one umbrella.
Do not Neglect the Emergency Department (ED)
Remember, outpatient setting is not a location, but rather a time frame. Most people will picture of facilities located outside the four walls of a hospital when thinking of outpatient facilities. But all such outpatient facilities may well be situated inside the hospital, as long as patients are not staying overnight in them.
Replace Obsolete clinical areas with state-of-the-art services. . Work on the aesthetics and ambience of the hospital lobbies that improves the circulation patterns of patients. Ensure that the outpatient facilities inside the hospital get enough natural sunlight. In short, the hospital floor should not give off the doom and gloom image where you dread having to wait or worse be stuck there. It should be a highly efficient center where you can get all the testing that you need, see whomever you need to see, and be out on your way. Every patient walking in through the hospital door should be looked at as an outpatient case first.
Though a pharmacy was not covered in our list of outpatient care sites as it only involves the stocking and dispensing medicine, medication adherence is absolutely crucial to optimizing health outcomes .An outpatient pharmacy is a standalone pharmacy or one within a hospital that dispenses medication for patients leaving the hospital, or those that do not need admission. . Some studies have suggested that as much as 25% of patients do not have even pick up their medication the first month after discharge. How to achieve coordination of medication management for such folks where they are not hampered by transportation or financial issues falls more into the care coordination realm. But what can be said is that where there is a chance for a hospital to own a pharmacy, it should definitely proceed with the acquisition. Working with a third party for medication is simply too big of a risk when it can be brought under the fold of total outpatient care strategy.
Look to The Horizon
First there was inpatient, then came outpatient, telehealth is all set to be the next big thing if it already hasn’t been acknowledged as such. Included in telehealth are videoconferencing, texting, sharing files and remotely monitoring vital signs of patients. Telehealth adoption becomes more mainstream with each passing year for all of its different modalities. Some people also like to categorize mHealth under telehealth, though it is more a device through which telehealth is administered, and not a component of telehealth itself like the 4 other actions mentioned before.
Indeed, alongside all of the outpatient facilities mentioned in this list, there is another outpatient facility that lives in the technological realm in clouds and servers. This is the virtual care marketplace, where many are choosing to see a doctor via online for the first time, or report symptoms online before even contemplating an office visit. If you do not have a way for patients in your community to engage with your physicians virtually, then you are conceding ground to the large telemedicine companies out there who will only be happy to make their network of physicians accessible to the public. Arm your physicians and other clinical staff with telehealth tools, so they can maintain their competitive edge in the market by maintaining virtual presence. Here are some ways how technology via telehealth impacts your outpatient growth potential:
Add bolt-on Solution
Bolt-on solutions are those solutions that work side by side with the main EHR of the healthcare organization, instead of integrating with it. There is a lot of noise about healthcare interoperability, but there is a still a long way to go before the industry can be truly interoperable. There are always issues in transferring patient data, and different legacy EHRs and EMRs have integration issues which are a pain to deal with. Rather than holding out on the promise of one centralized cross-organizational system, it is wiser to take advantage of the technology that is out there that promise a return on your investment. To illustrate this point, Northeast Georgia Health System, a 557 bed inpatient health system, grew its point of service collections from $258,000 to $7.2 million by electronically becoming the easiest destination care setting for patients of 700 independent physicians and 100 employed physicians. It was able to achieve this by utilizing cloud-based solutions that promised and delivered a good ROI. The fact that it was a bolt-on solution was no issue, as the promise of system to system interoperability still eludes.
One form of outpatient facility that has been flouted over the years is the educational center. Health care library with computer terminals are places where patients can research their own conditions and treatments. Thanks to telehealth however, such patient education can now be digitized and administered remotely at the convenience of the patient.
Remote Patient Monitoring
The truest form of outpatient care is perhaps home care, as not only are they not spending nights at the hospital, but they are not even having to step outside their door to other outpatient facilities mentioned in this post. Through remote patient monitoring, providing such type of continuous care for patients who have chronic conditions is possible. Health systems can develop such remote outpatient care processes for their primary clinical programs. Remote Patient Monitoring is a reimbursed service by Medicare since 2017, and organizations should explore if they want to develop such programs or outsource them to a third party who will do it for them. It will consist of devices, monitoring platform, staff time to initiate patients, staff time to perform patient set up and staff time for billing.
Healthcare systems expand outpatient care budget with new technologies such as EHR and telehehealth systems. EHR systems will improve data flow between inpatient and outpatient settings leading to greater care coordination for patients. Care coordination is another subject by itself that deserves its own guide. We have written about it extensively in this post. Check it out.
mHealth Leading to Better Engagement and Experience
The mobile healthcare market, or mHealth is also gaining traction rapidly to the popularity of wearables and fitness apps. Combined with remote patient monitoring, it serves as one mobile app through which televisits, care coordination and the transmission of vital signs remotely can all happen. If a health system truly envisions outpatient care for the future, it needs to work on patient engagement. Besides care provision, technology such as mHealth also simplifies patient experience. Patients are able to self-register and pay their bills online .
Prioritize High Growth Service Lines
At the end of the day, the healthcare business like any other business, is about the product. Service is important as well, but an organization should have an identity as to what it does (product) before performing that activity well (service). In order to maximize on both revenue and cost-cutting, it is best to understand what you do best and then rationalize those service lines to efficiently serve your catchment area without wasting any resources.
Intermountain Healthcare identified 30 clinical work processes accounted for over 85% of outpatient clinical volume. These processes were grouped into clinical programs. These outpatient lines were managed with end goals in mind. Some examples of these programs and their achieved goals are stated below:
Asthma- Increases use of controllers and a decrease in emergency department visits
Diabetes- Decreased HbA1c levels
Depression- Increased satisfaction among physicians and patients
All the listed conditions above are chronic conditions, and chronic care will always constitute the bulk of healthcare expenditure. It is a source of predictable revenue that will always exists, and thus it’s best advisable to manage them via outpatient programs that verges into home care. As long as you are able to keep the patients out of the hospitals, and confine their healthcare excursions to clinics and test centers, you can keep the costs down while continuing to leverage this predictable source of income. As this is a prime example of value-based care, it’s an instance where you can take advantage of more lucrative quality-based contracts or capitation models that we mentioned earlier. If you have enough longitudinal data on patient health of such outpatient segments, you can even consider taking on double sided risk models for a shot at higher revenues.
Looking beyond chronic care, a healthcare system should engage the whole patient population, even those patients without chronic conditions. Long before a patient is admitted into an outpatient or home care stream where a chronic disease is managed, they will need to visit the clinics to be diagnosed that will likely involve tests and may involve consultations with specialists. Such instances also fall under outpatient care as they patient is not admitted in the hospital overnight. In this list of top 10 profitable specialties, the 4 specialties related to chronic care are: departments of Cardiology (invasive and non-invasive), pulmonology, and oncology, mapping to heart diseases, COPD and cancer respectively. Internal medicine and gastroenterology are also featured which focus on the prevention of diseases and the stomach respectively. The other 4 specialties are all surgical, and thus from acute care, the need for which we already addressed in technological innovation section. The need for acute care service lines is a staple in any outpatient growth strategy.
Cancer is not usually associated with chronic diseases the way heart failure, COPD or diabetes are. But oncology is a great avenue for outpatient care as it involves patients receiving chemotherapy in outpatient settings. In case of cancer surgeries, that too is conducted in outpatient surgical centers. Like oncology, neurosciences is not commonly associated with chronic care, but Alzheimer’s and dementia are in fact listed as chronic conditions. While neurosurgery is a high growth area, hospitals are paying more attention to neurology cases as well.
Make the Push to Ambulatory Surgical Centres (ASCs) from Hospital Outpatient Departments (HOPDs)
Both ASCs and HOPDs are outpatient facilities. In choosing between ASCs and HOPDs, one should know that HOPD offers a better reimbursement, but that due to payment reforms the reimbursement for ASCs is rising at a faster rate at 2.1%, compared to HOPDs’s 1.4%. But as there is pressure to shift to more value-based models of care, it is not just about payment per service, but providing that service at a lower cost. This is where ASCs really excel as they are freestanding structures offering lower cost surgical settings, as opposed to HOPDs, which are usually attached to a hospital. The revenue from ASCs was projected to grow at a healthy 5.83%.
Hybrid Operating Rooms are operating rooms that are equipped with the sort of technology that is needed for minimally invasive surgical procedures. Thus both open and minimally invasive surgical procedures can be performed at the same time, in one go. Due to the shorter recovery times as patients recuperate from just one surgery, they are able to be discharged quicker and utilization of patient management resources decreases as well. Where ASCs can’t be developed, the operation theaters in HOPDs can at least be converted to hybrid operating rooms to conduct more same day discharge surgeries.
Sometimes procedures are conducted inpatient only simply because it is decreed by law. Keep an eye on the removal of procedures from the inpatient only list. As late as 2019, CMS removed 6 spinal procedures from its inpatient-only list. Healthcare regulatory agencies throughout the world have similar guidelines which get revised periodically. It is important to keep track of such changes in regulations, as every procedure is more profitable when conducted at an outpatient setting.
Focus on overall bottom line instead of individual service line profits and losses. Having a strong focus on outpatient service lines may cannibalize from some of your inpatient service lines.
Stand out from The Competition
The service lines you offer has to have a value proposition distinct from other healthcare systems in your state/province/county. It is wise to analyze the market first in figuring out the Community need in respect to the geographic location. The demographics of your community may have certain preferences that you need to adhere to. On the other hand, healthcare tourism, both domestically and internationally is a real thing, and some health systems will position themselves as the world leaders at a certain specialty or providers of the most hospitable care where the focus is more on luxury instead of just efficiency. They will have deals with payors whose customers pay a hefty premium for the best in class services. Ultimately, you will have to know your market. Regarding the outpatient market specifically, it is a hotbed for major innovations. Focus on the specialty growth areas. Orthopedics, spine and gastroenterology outpatient centers are growing as reflected by the ASCs that perform those surgeries. Within orthopedics, sports medicine is another specialty growth area with a good payor mix and positive outcomes leading to consistent reimbursement. Some hospitals have added a hyperbaric chamber to stand out from the competition.
Proceed with Caution
Quick efficiency first outpatient care is very different from slow caution first inpatient care. As such there are certain thing a health system should watch out for. Everything advised in this post is geared to distill the importance of outpatient care in your mind and provide ways for you to capture outpatient growth. But as with any strategy, one should be wary of the downsides or pitfalls. The good news is by knowing what these factors are, one is able to address them, thereby making their outpatient program even more robust. Here are some things that you must consider about outpatient care.
Efficiency Comes at a Cost
The appointments are very short, 10-15 minutes per patient. Thus diagnostic errors are more common.
Sterilization is Better in Hospitals
Infectious disease control needs to be taken seriously. Hospitals are already prepared for this, as they know the importance of sterilization. But when talking about ambulatory surgical centers specifically, the Centers for Disease and Control found the ASC setting to be safer and cleaner for performing surgeries.
You May Need to Adapt
In events which limits access or increase utilization of resources such as physicians, nurses, laboratories etc., outpatient facilities may be closed to redirect efforts and resources to other areas. They can also be used as a buffer zone for emergency services, if used properly. After hours program can be started for outpatient facilities, ED visits was decreased.
Downstream to upstream care, where primary care taken on more value-based contracts and manage total health. Going from fee for service to value-based increases profitability by at least 25%.
Not only is an outpatient clinic less expensive to build than a hospital, but operating costs associated with overnight stays, mechanical, electrical systems and more are reduced as well
We hope you find this primer on outpatient growth useful in crafting a strategy for your healthcare organization, or even just to learn about the subject. Please feel free to share this content with all.