Those of us in the trenches of medical care are always seeking new ways to improve our practices. This means we must be willing to try new things, and not infrequently we are often pleasantly surprised when our experiments succeed!
Over the past few years, government bureaucrats have spent a lot of time and effort informing physicians how best to provide medical care. The consequences of this healthcare overhaul have been high-deductible insurance, burned-out physicians, and frustrated patients. While we optimistically wait for healthcare “reform” to be reformed, there is much we providers can do to improve the care we offer patients.
A major dilemma for patients is simply how to access good care that is both convenient and affordable. Complicated electronic health records (EHRs) and paperwork have reduced the number of patients a physician can see per day. Patients often cannot be seen by their primary care provider (PCP) because of long waits on the phone and triage systems that often misdirect patients to emergency departments. Thus, patients are abandoning their “medical home” and seeking care elsewhere. This means that patients are using retail-based clinics that have extended hours and competitive prices for the uninsured or underinsured, and are being tempted to utilize the $49 telehealth visits promoted by some insurance plans. To thrive in these challenging times, practices should consider all options to facilitate patient access. If you have an open mind, you may even consider changing your “traditional” practice to one that provides “direct primary care.” Read on.
Before we continue, it’s worth mentioning that there are numerous ways to make pediatric practices more efficient, with the goal of increasing capacity beyond 20 patients a day. Simply by increasing capacity by just a few patients each day, you improve patient access (and increase practice revenue)! Methods that can help accomplish this goal include: 1) improving use of EHRs (or using scribes); 2) using technologies to expedite diagnosis and screenings; 3) having age-appropriate scales in exam rooms (to improve traffic flow); and 4) having staff assume new responsibilities (recording chief complaints, giving vaccines if they do not do so already, and so on) so that the provider’s menial chores are minimized when you enter exam rooms.
Adding capacity also means that you have a mechanism is place to optimize scheduling of patients. This means minimizing “no-show” appointments by enforcing a strict office policy that makes these events rare. It also means anticipating the need for sick visits by keeping same-day slots available depending on the day of the week and the season of the year. Most practices see more patients on Mondays and Fridays, with fewer patients seen during the middle of the week.
You can also improve patient flow by adopting a “wave method” of scheduling appointments so that you book 2 patients for the same time slot and see whoever shows first. Many practices that use this system report that it improves workflow significantly. Another option is to provide evening hours if you anticipate that you will see more patients with extended hours and not merely displace patients that are usually seen during the day to your evening hours.
I’ve spoken to some pediatricians who have lost patients to convenient care clinics in their neighborhoods. They have regained patient volume and allegiance by implementing a walk-in clinic type of practice during certain hours, and staffing appropriately. The bottom line is, if you are willing to innovate, you can improve upon your present system and increase capacity without working harder. You can even consider adopting a very successful system for scheduling patients that is nearly 20 years old, called Open Access Scheduling (OAS).
Open Access Scheduling
The OAS system was invented by Mark Murray, MD, MPA, and Catherine Tantau, BSN, MPA, at Kaiser Permanente in Northern California in the early 1990s. The essence of this system is scheduling patients on the same day they call, no matter what type of visit is requested. So, rather than having wait times in the order of 50 days to see a patient’s PCP, OAS changes this to a system that facilitates same day visits with PCPs!
Under the traditional model, a provider may be fully booked on any day, and if no same-day slots are kept open—and overflow patients must be seen—the provider becomes double booked. This overwhelms providers and staff. The alternative model is a carve-out system in which at least 50% of visits are booked ahead of time, with the remaining number of slots kept open dependent on the day of the week and season, as well as the capacity and work habits of the PCP.
Under the OAS model, the number of prebooked visits falls to around 30%, and these represent recently booked patients who prefer not to be seen on the day they call. To make OAS work, providers need to clear up any “backlog” of visits, most notably preventive health visits, which can take some practices weeks or months depending on the willingness of providers to pitch in and work extra hours. Practices that wish to implement an OAS system can consider adopting scheduling portals such as Appointment Quest (www.appointmentquest.com/), which enables patients to book their own appointments without calling.
Practices that have implemented the OAS model, once fine-tuned, rave about how it expedites care and pleases patients. When patients call, the staff first ask who is their PCP, and secondly if they would like to come in for a visit that day. According to Mark Murray, in the open access system “providers do today’s work today,” rather than chipping away at a backlog of work. This model is particularly relevant now, when patients are seeking care at retail-based clinics because they can’t get in to see their own physicians.
Panel size matters
If you wish to consider adopting the OAS model discussed above or just want to make your present system work better, you need to realize that physicians have a limit as to the number of patients they can accommodate in their panels. To function as a PCP, one must attend to all the needs of patients, not just see patients for preventive health and ill visits. This involves calling patients to address concerns, generating referrals and school forms, refilling medications, and more.
Panels sizes have been extensively analyzed by experts, who have developed complicated algorithms for computing ideal panel sizes. Long story short, however, a full-time pediatrician’s panel typically caps out at 1500 to 2000 patients, depending on the complexity of patients, number of daily available appointments, and number of support staff. It is unfair to the patients to bloat panels beyond that which the practice can handle. Once a provider panel gets to a critical size, it should be closed and patients directed to other providers in the panel, or additional providers should be hired.
Direct Primary Care
The Affordable Care Act (ACA) has led some physicians to create a new model of healthcare delivery, one that can bypass insurance coverage and enable physicians to focus on medical care. This model is called Direct Primary Care (DPC). It entails having patients subscribe to your practice for a monthly or yearly fee. No insurance companies are billed and no co-pays are collected. Patients are advised to have catastrophic health plans in case they need hospitalization, medical tests, or surgery.
In the DPC model, physician panels are capped at 600 to 1000 patients, allowing physicians to do well economically while affording patients ready access to their PCP. In most DPC models, office testing is billed to the patient at cost. Doing the math indicates that if you have patients pay $60 per month per patient ($720) per year, a 1000 patient panel generates $720,000 per physician per year. Even if your overhead remains unchanged, then physicians often make more than they would under traditional models of care. Usually the overhead decreases as well because you are no longer billing patients, and you hire fewer staff because you see fewer patients per day than you would under the traditional care model.
Physicians as well as patients praise this model because wait times are minimal, and visits are longer and unrushed. Obviously, you could not transition to a DPC model if you have a significant Medicaid population in your practice.
Food for thought
There are a multitude of ways physicians can facilitate patient access to care. Choices range from improving practice workflow so more patients can be seen per day, to making changes to your scheduling system. Physicians who wish to change their practice model entirely might consider adopting a DPC model of care. Although the choices are many, only you can decide if your current system is working well. If not, consider the many options discussed in this article.