Does the size of a patient's balance following care influence his or her decision to return to a provider in the future?

That was the question researchers sought to answer in a recent analysis of data from the athenahealth network. Most practice managers know how difficult it can be to collect large patient obligations and are mindful of the impact noncollection can have on the bottom line. The effect of balance size on return rates is less obvious – but has the potential to hold just as much sway on the fiscal health of the organization.

Researchers reviewed data from 13 million commercially insured patients aged 18 – 60 who visited 51,000 physicians in 2015. For a practice, and its patients, to be included in the sample, it had to be active on the athenahealth network for two full years between 2015 and 2017.

To begin, analysts segmented patients according to what they owed following their initial visit ($0, $1-$50, $51-$100 and so on). Then, explains Josh Gray, vice president of research at athenahealth, they looked for return visits by these same patients at any point over the next 24 months.

“What we found was disquieting," Gray says. “The more patients owe their doctors, the less likely they are to return." Among primary care patients who owed nothing after their initial visit, 85 percent returned within 24 months, for example. But only 54 percent of PCP patients came back when they owed between $100 and $200, and just 42 percent returned when their balance was over $200.

Across specialties, orthopedic patients were the most sensitive to balance size, with their return rates dropping 45 percentage points when their balance was over $200 compared to when they owed nothing. Cardiology patients, on the other hand, were the least sensitive to what they owed, with their return rates falling about 29 percentage points between the two balance extremes. (The other two specialty categories analyzed in the study, obstetrics-gynecology and internal medicine, saw 33 and 32 percentage-point declines in their respective patient return rates.)

Perhaps the most worrisome finding in the data involved return rates among PCP patients with chronic conditions, Gray says. Patients with claim diagnoses for depression, hyperlipidemia, diabetes, COPD, asthma or hypertension returned 91 percent of the time when they owed nothing for their initial visit, but just 49 percent of the time when their bill topped $200. “Patients with chronic disease are more likely to return than those without chronic conditions, which is what we would expect of patients with potentially serious health problems. But they're still showing sensitivity to balance size, and I think that raises serious concerns."

The worry? Many of these patients will be back eventually, “but presumably at a time when their health is much worse," Gray says, "and that could generate even greater costs."

Chris Hayhurst is a writer based in Northampton, Massachusetts.

Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.