Editor’s note: This article was adapted from a paper submitted toward fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about ACMPE certification: mgma.com/acmpe.
Access for all patients who want to be seen — that’s the underlying objective of the organization’s mission statement. To support that mission, the medical group embarked on a Patient-Centered Medical Home (PCMH) journey in 2015, putting the primary care physician in the lead position for patient care. The PCP then created a team of caregivers who took responsibility for overall patient care. In addition, the team became the advocate for the patients, ensuring they receive appropriate care from other qualified providers. This treatment plan is essential to meeting patient needs.
By 2017, all the group’s 19 primary care clinic locations were recognized by the National Committee for Quality Assurance (NCQA) as Level 3 medical homes, and that status has been maintained for all initial and new primary care offices across the organization. This PCMH designation is a practice-level initiative focused on identification of high-risk patients and proactive coordination of their needs outside the clinic. PCMH also places a heavy emphasis on patient access and requires practices to attest to same-day patient access, among other office workflows.
Key facts
- 200-provider independent, integrated medical group that’s one of the largest physician-owned multispecialty groups in North Carolina and the southeastern United States
- More than 60 locations with 100+ physicians, 100+ APPs and more than 800 staff
- Group operates its own reference laboratory, outpatient diagnostic radiology testing facilities, two urgent/express care facilities, an endoscopy center and other ancillary services.
As a component of its PCMH journey, the group built a centralized care coordination department. Clinical programs include chronic condition management (CCM) and transitions of care management (TCM). Care coordinators are given autonomy to schedule post-discharge follow-up appointments in PCP schedules; however, schedule decentralization leads to the care coordination department having to deal with individual offices to schedule patients. It is a time-consuming and confusing process, as the rules are different in each office. PCMH requires primary care practices to hold open appointment slots for a hospital transitional appointment and same-day sick appointments to enhance access to both patient types, but it is not enough.
The group’s culture is characterized by a pride in independence, and operational autonomy is strongly valued as a result. Centralized functions such as business services/revenue cycle, coding, quality/provider engagement and human resources are high-functioning departments; however, standardization initiatives sometimes are met with skepticism, especially when they involve a perceived loss of physician autonomy. Providers dictate their office hours, scheduling templates and availability, and only in very specific circumstances (e.g., care coordination transitional visits) are centralized functions permitted access to their schedules.
Poor access can be a function of poor supply by provider organizations, inefficient operations/deployment of assets and excess capacity. Each office determines when a patient can next visit their office and for how long. Providers believe that only their office can manage this process in a way that allows for the proper amount of time for the patient’s concerns to be dealt with and give the provider a schedule that will allow them the ability to get through the day. The reality is that a centralized scheduling department can learn each office’s nuances and create consistency in scheduling activity.
Centralized scheduling can be funded from the operations of the practice, and the cost of the project will be limited to staffing, furniture and space. Most of the staff will be transferred from other departments. The only incremental cost will be the hiring of a manager, the furniture and the cost of the space. Over the next three years costs are projected to increase 2.5%. This will include wages paid and all other expenses. As the project is projected to increase the number of office visits each provider can perform, the new department is projected to pay for itself with less than one additional office visit per week.
Management and buy-in
The responsibilities for this department will be assigned to one of the directors of operations (DOO). They will hire a manager for the department and work with human resources to identify staff to move out of the practice locations and into the central scheduling department. The movement of staff must be approved by the doctors in each location. A DOO will be responsible for assembling a team to get this new department up and running.
One of the biggest challenges this department will face is convincing doctors that their schedules can be managed remotely to the benefit of the patient and the doctor. The practice will need to market the benefits prior to implementation as well as report improvement regarding key performance indicators (KPIs). This will be an ongoing effort that will also be looked at from a cost standpoint as the group monitors the ongoing patient cost of care and any resulting shared savings that the group is entitled to because of savings in the overall spend of healthcare dollars.
Business competitive advantage
The group’s goal is to provide something its competitors don’t do or can’t do. In this case, the group is able to offer high-quality care combined with lower cost care, which stands in stark contrast to increasing costs at hospital-integrated organizations.
To ensure patients receive the most value for their healthcare dollar, they must know what an independent physician or hospital can provide in terms of quality and cost. To that end, the group must help patients access and understand this information so they can price shop.
Financial information
This project will require little capital. The department projects 40 full-time staff in this department, as well as phones and workstations for all.
About 3,000 square feet of space is needed at a cost of no more than $25 per square foot. Phones and cubicles will cost no more than $75,000. The small capital costs will be financed using the practices’ capital line of credit. Once all 100 PCPs are using the new department, it will pay for itself the first year. This doesn’t take into consideration any long-term potential bonus of reducing the overall cost of care.
Organizational plan
The group has participated in value-based care reimbursement for the past three years in partnership with the local not-for-profit hospital. This year the group stood up its own accountable care organization (ACO).
Typically, the decision to open a centralized scheduling department would not be very complex. But combined with the desire to improve access, lower costs and ultimately attract other PCPs to the practice, the move becomes a key initiative.
Defining the problem: Access to care
To date, patient access to medical services has been reactive and structured to provider and staff preferences rather than those of patients. Healthcare organizations are beginning to recognize the relationship between a product’s quality and the ease with which it can be accessed.
Patients are asked to access care from 9 a.m. to 5 p.m., Monday through Thursday, with little access on Friday and the weekends, which pushes wait times for clinic access out to several weeks.
If the group believes lower costs come from better access, as demonstrated below, that issue needs to be addressed by the group.
Problem size/identification of metrics
To determine if central scheduling is warranted, the group needs to review current practices. What follows is a SWOT analysis specific to the central scheduling department.
Lower costs come from more and timely access to primary care,1 so the group needs to determine if there is an access problem caused in part by its scheduling process. To appropriately determine the need (and to validate if a problem exists), a set of KPIs tied to scheduling were identified for the group’s patient population and are reflective of the group’s current scheduling practices. KPIs are identified, after which benchmarks are sourced. Performance can then be assessed relative to benchmarks and organizational KPI trends. Once the proposed solution is implemented, improvements in these KPIs will be monitored to gauge success/failure and to augment implementation tactics.
KPIs include:
Third-next-available appointment (TNAA): The measure of the delay patients experience in accessing providers for a scheduled appointment. From the provider’s view, it is simply the third slot open on the schedule. It helps the provider understand how hard it is to get in to see them. From the patients’ point of view this indicates if they have reasonable options to see the provider. If this number gets too high, the patient will begin to look elsewhere. The Institute for Healthcare Improvement (IHI) has a goal of zero (same day) days for primary care and two days for specialty care. The group will use IHI’s goals as its benchmark for this KPI.
A sample was taken of the group’s offices to determine if there is an issue with the TNAA KPI. Table 2 shows the data sources from the group, looking at 18 providers.
The averages for primary care and specialty physicians and advanced practice providers (APPs) are well above the best practice standard of zero days for PCPs and two days for specialty providers. While there were some providers who were able to meet the best practice standard, there were other providers who worked in the same office who fell well below the goal. The practice will continue to review other KPIs to see if the scheduling challenges impacting a patient’s ability to see their provider continue.
Three other KPIs will be used to determine if other deterrents exist:
- Average speed to answer
- Call abandonment rate
- Average wait time in queue.
Below are definitions of these KPIs, as well as best practice numbers that will be used to measure how well our practices are doing.
- Average speed to answer: This is a call center metric for the average amount of time it takes for calls to be answered. The formula is average speed of answer=total waiting time for answered calls/total number of calls. The benchmark average time to answer, as determined by a study done by Talkdesk for 2018, is 3.22 seconds. The longest people are willing to wait is one minute and then they try to find a resolution to their problem elsewhere or ignore it.
- Call abandonment rate: This is the percentage of inbound calls disconnected before they speak to someone. Using the Talkdesk study, the practice sees that on average 13% of calls in the healthcare industry were disconnected before the caller was able to speak to someone.
- Average time in queue: In healthcare, callers spend 2.25 seconds in the queue before they are connected to a live person. Making a caller spend too much time waiting accounts for 75% of disconnections.
Data from 2019 for six different practices showed similar results to the other offices, so the sample was deemed valid across all offices. The Cisco phone system (deployed throughout the entire practice) shows total call count, total answered calls, total abandoned calls and the number of calls forwarded to voicemail. From these statistics, the group will calculate its KPIs to help determine our need for a centralized scheduling department.
An analysis of how well the group’s individual offices are doing compared to the identified KPIs showed the following:
- Speed to answer averages 17 seconds compared to the desired 3.22 seconds.
- Call abandonment is 13.3% compared to the desired 13%.
- Time in the queue can be up to 60 seconds, rather than the desired 2.25 seconds.
The result of the data analysis shows that there is significant room for improvement, which should lead to better coordination of office schedules, ease of filling open appointments, a lower rate of no-shows and an increase in the number of filled appointment slots for primary care providers.
The group serves more than 128,000 patients each year, which created the need for 1,080,000 appointments in the health system. With almost 20% (195 staff) of the entire group working on scheduling in some capacity, the practice needs to do a better job scheduling patients to improve PCP productivity, increase the number of times patients see their PCP and ultimately drive down cost to the healthcare system.
Proposed solution
By creating a centralized scheduling department, the group will benefit from the ability to fill provider schedules and drive down healthcare costs with improved access to primary care. This department will force standardization in the scheduling process and give patients a consistent experience and assurance that they will be seen in a timely manner.
The department will maximize staff from all primary care offices and may realize some cost savings as the department matures. This department will also allow the individual offices to concentrate on patients. The expectation would be to see improved customer satisfaction, more accurate information being entered into the computer system for each patient and better collection efforts when the patient is in the office. The perception will be that management has more control over their workday, so provider champions will need to lead the change and show that the benefits outweigh any perceived obstacles.
Implementation plan
The plan to implement centralized scheduling will need to be carefully considered. First, the group must assemble people from the impacted offices, including providers and office managers. In addition, the medical director and the director of operations will be responsible for the department. Ongoing meetings will be scheduled to discuss the planned change, issues and progress. Compliance with this plan is not optional and the group is prepared to further educate providers to help them get on board with this change.
Next, the group will look at existing schedules to determine the best timing for making the change. This will involve moving employees into the new location and providing education on scheduling in all locations. Once the education is completed and the space is finished, a cutover date will be selected by the group. IT, phone and management will be present to support the new department and assist as needed during the first days. Ongoing activity reports will be run to determine the impact to new staffing levels. Prior to the establishment of the new department, reports will be run for each office to determine volume levels. Project leaders and providers will participate in ongoing meetings to review this data to show the anticipated benefits of the change.
Marketing will develop material to educate patients about the change and minimize any confusion when they call the office. In addition, a marketing plan for the doctors and staff will be developed to discuss the anticipated benefits of the new method of scheduling. A system of patient feedback will be established and reviewed during the leadership meetings. The review process will continue in some manner for the foreseeable future to monitor the impact to the no-show rate, the number of times patients are scheduled to see their primary care provider annually, as well as determining the correlation between this department and value-based cost savings.
Conclusion
The pandemic has further brought to light the need for a central scheduling department. When an issue significantly changes the number of patients coming into a clinic, the number of offices that are open or even the number of staff available, a central department will be able to flex to meet patient demand much more efficiently than staffing each office.
COVID-19 has taught the group that it can no longer do things as they have always been done. Customers demand more, and the cost of care can’t keep rising. The overall benefit to the ACO will not be recognized for several years due to the way costs are calculated by insurance companies. It will take several years of tracking the average number of times the practice sees patients along with the overall cost of care to discover the project’s impact. The cost/risk to the organization is small and can easily be monitored for several years.
When looking through the lens of customer satisfaction, improved patient engagement, provider pay, number of patients seen per day and no-show rates, the group will be able to recognize the benefits of implementing a central scheduling department.
The opportunity to see more patients per day and drive down the no-show rate and cost of care with very little financial risk to the group must be considered. While there are risks, this is a well-thought-out plan, which should provide benefits to the group once fully implemented.
Learn more
For more in-depth financial projections of the plan outlined in this article, read the full ACMPE Fellow paper.
Note:
- Doty MM, Tikkanen R, Shah A, Schneider EC. International Survey: Primary Care Physicians in U.S. Struggle More to Coordinate Care and Communicate with Other Providers But Offer Patients More Health IT Tools. The Commonwealth Fund. Dec. 10, 2019. Available from: bit.ly/2VPHYat.
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