Beyond the obvious priority of improving the health of patients, you have a number of levers to push and pull when it comes to improving your revenue cycle. One of those levers involves better meeting patient demand with more availability from your providers. But how do you do that?
To answer that question, Nordic’s Director of Optimization Solutions Rick Shepardson sat down with Nordic Senior Consultant Andy Palmer.
[02:00] How do we open up providers’ schedules?
[03:45] Driving better revenue
[04:42] Ensuring provider bandwidth
[06:20] Developing a better experience for patients
[06:55] Overly restrictive schedules
[09:07] Change management challenges
[09:55] Challenging the thinking
[10:45] The math adds up
[11:50] Expanding beyond your current capacity
[12:50] Lag time, third next available
[15:35] Department analysis toolkit
[17:16] Patient frustrations
[18:05] Data-driven decision making
[21:12] Managing both incoming and outgoing referrals
[22:40] Internal marketing
[23:35] Example of increasing revenue through these changes
Rick Shepardson: Hi. I'm Rick Shepardson, director of optimization solutions here at Nordic. I'm joined today with Andy Palmer, a senior consultant of ours.
Andy Palmer: Hi Rick, thanks for having me.
Rick Shepardson: Thanks for being here Andy. We've spent quite a bit of time talking about provider accessibility in the past and spent some time developing some solutions around that and with some of your previous experiences.
Andy Palmer: I've been working in this space for the last two or three years now, really taking a closer look at how accessibility can impact patient satisfaction, provider satisfaction, the bottom line of organizations, and really focusing on that to really drive outcomes.
Rick Shepardson: When I first started to talk to you, you were talking about provider accessibility, and I'm like, "Are we helping them drive to the office?" I didn't fully understand the terminology upfront, and I think as we've talked about it more, I've understood it a lot better. My understanding now of provider accessibility, how do we open up providers' schedules in a way? How do we maximize the time that they have and make providers more accessible to patients?
Andy Palmer: Certainly I think that's a big component of it, and then as you peel back the layers of the onion a little bit you find out that there's a lot of drivers into what makes a provider schedule accessible. It's not necessarily just how many hours you have in a day. It's what type of limitations have you put in there? What type of availability is there, so it really comes down to meeting the demand of your patient population and understanding where the different demand areas there are for those patients that are coming in and what type of services do they need? What's the time frame in which they need those services? How do we meet those demands? Then it peels off into other areas as being able to take in more referrals and allow other organizations to work with you in terms of working with patients and really driving that continuity of care that's really important for patients today. On the surface it seems like a really simple little concept. "Oh yep, I have x amount of hours and feel I can fill y amount of patients in that time." It goes into more detail in that when we understand all those different levers that can impact meeting the demand of our patient population. There is a lot of opportunity there to better serve patients and then also ultimately drive better revenue and see more visits and better outcomes overall.
Rick Shepardson: You hit on the revenue topic there at the end. Obviously the more patients you can see, the more revenue you are going to get, in a way, at least from an outpatient provider perspective.
Andy Palmer: Certainly.
Rick Shepardson: That is a big driver here. I think another driver is this shift towards value-based care and figuring out how to move your patient visits and patient care towards an outpatient setting as opposed to an acute care setting. There are a lot of challenges with that and in terms of how do we right size the visits? How do we need to leverage telemedicine, telehealth visits, and e-visits?
It's all of this provider messaging. How do you ensure that there is bandwidth for physicians to care for patients in these voluminous ways that meet their needs at the right place at the right time in the right way?
Andy Palmer: Yes certainly. I think that kind of goes to what we’re talking about before. Where you have to understand all of those different inputs. So you listed off a half a dozen of them that could easily mean a large amount of volume. It's not just patients calling in and saying hey I need an appointment or a follow-up appointment or things like that. It's supposed to start planning. It's those types of follow-ups. There's regulatory requirements and Meaningful Use requirements, and things like that factor into it as well. To really kind of understanding what all of those levers of demand and where that's coming from is a critical component to this. So that you can ask yourself the question is, How do I meet that demand? If I have a certain volume of patients that I know we're going to need follow-up visits following an inpatient stay, how do I meet that demand? And how do I balance that against the follow-up appointments that I need to have six months from now or a year from now? How do I balance all that out?
So, ultimately that's kind of one of the things that we really focus on is understanding where all of those demand inputs are coming from. And then, how do you address those? You have to really kind of state that problem discreetly to say, "Alright well I have this coming in from here, this coming in from there. How do I meet that demand? And how do I do it in a way that has energy for for my patients?"
Rick Shepardson: Yeah so then, understanding all those different inputs and developing a cohesive experience for patients is critical. Do you think that that's an area that providers and organizations are struggling with the most today, maintaining that balance, understanding all the inputs? Where else do you think they're struggling?
Andy Palmer: In my experience, what I've seen is that there's a tendency to overly restrict schedules and try to be very rigid in the way that patients come in. There is certainly a time and a place where we have to reserve certain times for certain patient types and visit types and things like that, but at the same time, we have to understand that kind of becomes a restriction in meeting our overall volume. We may reserve certain times for certain kinds of visits, but that's not necessarily the order in which the phone calls are going to come in or the patients are going to be discharged out of the hospital or basically kind of the way that the patients are going to be coming in to us. So, it's really important then to understand how those two mix together in order to be able to say if I call up for a certain visit type, when can I be seen?
If I'm reserving time for a different kind of visit, than I cannot come into that earlier time. So what does that do to me as a patient? It's really kind of taking a patient-centric view of things as well. I think another component too is, there is an opportunity to really address this and not incur additional costs. So, what I mean by that is that most of the time we're working within existing scheduling frameworks and looking at ways that we can either optimize schedule utilization, or looking at ways we could maybe insert a few time slots here and there. But overall, we're not really looking at increasing the number of hours that providers are working or anything like that. We're looking at ways that we can be more efficient and better utilize their time. So, that we're able to maximize our patient throughput in that supply of available hours.
Rick Shepardson: Yes, so I think that you mentioned patient experience and their role. The other two or three major groups that are impacted are the providers and schedules or schedustrars. To what extent have you faced challenges or experienced change management needs from their perspectives?
Andy Palmer: Yes, so I think one of the big challenges that I've come across like I mentioned before is moving away from a very rigid defined type of scheduling process where I say I want this kind of patient in at 8 a.m., this kind of patient at 8:30, this kind of patient at 9. Like I mentioned before, there's certainly a time and a place where reserving certain times – and there may be resource considerations or maybe timing considerations, patient considerations for a lot of those things – but, moving away from that model tends to be a little scary at times.
Rick Shepardson: Especially for providers right?
Andy Palmer: Exactly, and so really kind of challenging the thinking a little bit, I have to have a very rigid schedule in order to see patients in the order that I need my data run. It's balancing out against the way that the patients are going to come in. So, we really need to understand how well we're utilizing the overall provider time. And then also, within that, how well we're utilizing each of those individual slots if we do have those restrictions or those reservations put in there for certain kinds of patients.
Rick Shepardson: And then the carrot for the provider is probably ultimately the increased revenue if the schedules are full, the ability to grow their patient panel sizes, and see more patients overall.
Andy Palmer: Certainly. Yet and it becomes a pretty basic equation because at that point, we're not adding any staff or not adding any resources. Providers are already in the clinic. Your support staff are already in the clinic. You know, if we can add one or two slots per day or better utilize one or two slots per day, we go for maybe 90 percent schedule utilization to 95 percent. That equates out to maybe two patients a day. That's 10 patients a week. That's 40 patients a month. So it just snowballs from there, and then you multiply it by your average revenue from each of those visits and you can see just on one provider, how quickly they can multiply. Apply that across maybe 500 providers, then you're looking at some pretty substantial revenue growth in capacity that you already had in existence today. You're just better utilizing it or you're taking advantage of it more.
Rick Shepardson: Yeah. Making the most of what you have a lot easier than trying to bring on more and integrate that into your practice.
Andy Palmer: And you mention taking on more, but then once you master that that first component of it, of maximizing the efficiency and throughput of your provider schedules, then you can actually start looking at expansion and things like that. So if I notice that I'm maximizing my cardiologist schedules, and I'm very happy with where they are, I can still see patients in a timely manner, and I can still fill my schedules. I can meet the demand, but then I have the opportunity, and I recognize a need where I maybe could bring on another cardiologist or another specialist or things of that nature. Then we can look at expanding and getting a larger market share.
The other piece that I've worked with another client on is then making it marketable. So, if you understand how easily it is or how quickly you can get patients in, that becomes a marketable piece to your organization.
Rick Shepardson: That comes back to lag time. I think the industry standard is third-next available appointment.
Andy Palmer: Their next available is your industry standard for measuring your ability to get in to see any given provider and so ...
Rick Shepardson: And for the way people out there, right? Myself, included right? Third-next available is the time period which if I had three patients who came in and who we got requests for visits right away. When could we get that third patient in to be seen?
Andy Palmer: Yeah, it's actually your third available slot on a provider schedule. The reason why the industry kind of uses that third-next available as the standard, is that the expectation is the first available slot might be very variable. Meaning that, technically if someone were to cancel an appointment tomorrow, my next available point would be that time slot. But if I'm on a if I'm a very busy provider, on average it might take me a week. Maybe two weeks. Even longer to get in to see that particular provider. So, that first one, can have large swings in doing so they don't use that as a base measurement.
They go to the the third because then they kind of factor in while there's some patient preference that has to be accounted for as well. So, if that ten o'clock slot on next Tuesday doesn't work for that patient then how do we go for that next one. It tries to account for a little bit of the back and forth. When you maybe have first or second option isn't going to isn't going to be the right one for the patient. So the third one is kind of the one where the industry lands on to measure. The next thing is that you can measure either of those measurements. I know one organization I worked with, really focused on that first next available appointment. They wanted to find the first available time
Rick Shepardson: Same day appointments.
Andy Palmer: It's same day visits, but then also you had kind of like okay, how long does it take me to get into to see the future scheduled appointments. So, they understood that there's that variability there and you could go a week where the first next available point might be ten days from now. It might be two days from now on average so you have to account for those swings. To understand exactly where that where that lies.
Using the third one how kind of gives you a little bit more of a static measurement. And gives you probably a better picture overall over the course of time. What is my average accessibility for a particular provider?
Rick Shepardson: So that was one of the coolest things that when we started working together, I really liked was the reporting package that you had put together with one of your previous clients. Understanding what the next available appointment time slot was. Understanding how much flex time or available time actually existed on provider schedules. So you know, if you could maybe talk a little bit more about that tool that you created from reporting perspective and how it came into being and why? I think that would be ...
Andy Palmer: Yeah, so the kind of department analysis tool kit that I put together, I really tried to identify not only just the accessibility measurements but one of the other driving factors in your quote-unquote provider accessibility overall. It's not just your third-next available because there's a lot of different variables that go into that. So as you mentioned, there are things like, you know, schedule-restricting types of things like private slots or reserving for certain visit types. That can impact things. How do you measure those?
The other thing I started looking at them too as we as we kind of dove into it more deeply, was looking at utilization. So I have 10 hours, maybe eight hours a day of schedule time. How many of those hours am I filling with patient visits? And then what is my success rate of having those patients come in? What's my notional rate? All of those things are impacted by the appointment lead time. The further out you schedule an appointment, the more likely you are to reschedule it or have the patient no-show or cancel.
We had one particular department that their average lead time was about three months or so to schedule an appointment. It took almost three months – actually longer than three months – to get in to see a provider. They had a 67 percent rate of rescheduling or cancellations or no shows, meaning that two out of every three appointments they had to touch again or redo again. That's a lot of extra overhead for your schedulers, for your doctors and other resources so ...
Rick Shepardson: Probably a lot of unhappy patients too because they're not getting in to be seen.
Andy Palmer: Absolutely, and this particular customer had a lot of patients that came in from other areas of the state. And some patients would drive a long way and not be able to secure their appointment. So there was a lot of frustration there. That kind of spawned some thinking that we said, well, we have to kind of look at all of these different components so our excess ability or utilization are a point in volume.
But then also kind of look at those in a big picture way. Each one of those individual measurements doesn't paint the entire picture. So I could have a very accessible schedule, but if my utilization is 65 percent, that still means that I'm not filling my day up, and I'm not seeing enough patients. Then we have to ask why or why is this happening? If I have a really high utilization, I have to understand do I have the right amount of hours available? So if I'm a full time provider, and I have 105 percent utilization, but I'm only available for four hours out of the day, that means I'm kind of artificially cutting off ability as well.
Now I can only see maybe 10 patients a day when maybe I could be seeing 20. You just play with the numbers a little bit. You kind of factor that out. As you start to paint that broader picture, you can start seeing trends. While if I have low utilization and high third-next available or high excess ability measures. That's a good indication that I have a very restrictive schedule. If I have high utilization alone at their next available, that means that, I have a good amount of flexibility in getting patients in sooner.
So, we want to try to find those sweet spots. And those sweet spots are going to vary from clinic to clinic or specialty to specialty, because there's just different demands from a patient population as to what that's going to be. Really what I did with the toolkit is almost down to the provider level, so that the specialty areas can focus on their providers versus maybe the family or internal medicine providers can. Clinics can focus on those providers and then look at all of those different levers and all those different inputs and say OK, well, this is what I need to do in order to execute what I want to do from an efficiency standpoint, in a throughput standpoint, in order to to maximize my ability to to see the patients that I need to see.
Rick Shepardson: So really, what I think you're describing is the trend in the industry at large is data-driven decision-making.
Andy Palmer: Certainly.
Rick Shepardson: Once you have the data and it becomes accessible, then understanding the balance and where you're at in terms of your third-next available versus capacity versus billion and willingness to change. Then maybe you're engaging your marketing department to increase outreach and promote and try to increase volumes. You have a driver to reach out to external providers to increase referrals because you know you have excess capacity that could be used. Then you're able to market that an effective way. Maybe it's managing schedules better and building out a maintenance processor a more effective way to keep them up-to-date. Keep the provider schedules fluid and well-filled, right?
Andy Palmer: Yeah exactly, and I think you touched on a couple of really great points from this type of effort. So it can transition really well into managing both your incoming and outgoing referrals. From an incoming perspective, how do I then do market outreach and get out more into the community to say, "Hey we can take these types of patients or we want to see your patients so we can provide this service"? We can get them in within a week or two weeks, or we can make that commitment, and you can feel confident in that commitment.
I think that's one thing I've noticed in my work as well is that most organizations are a little leery of making those types of commitments because they've been burned too many times with patients, or you're working with other organizations or other clinics in the in the area and say, well, you told me I could get somebody in within two weeks and this patient took a month. And there's always that one exception that can kind of spoil the experience for those types of things. It's a really helps solidify your confidence in being able to do that type of thing.
The other piece then too is understanding where all your referrals are going? If I'm sending a lot of patients out to other organizations in the community, where are they going? Why is that? What am I doing in that type of thing? Can we handle that population ourselves?
Rick Shepardson: And then promoting that back to providers.
Andy Palmer: Exactly. You're almost marketing internally. Your providers are generally going to send their patients to where they can be seen in the appropriate amount of time. I've seen some statistics that second pretty much only to refer and provider ability and capability. The next most important thing is being able to get their patient in a timely manner.
Rick Shepardson: Patients have needs, right? Patients are sick. They need to be cared for.
Andy Palmer: Exactly. Yeah so there's a huge time component to it, and so what better way to serve that patient than if you can keep everything in-house. You don't have to go through registration hoops. You don't have to do a lot of extra referral work. You don't have to do a lot of authorization work. It's already in-house. It's already kind of ingrained in your system. Why not redirect those patients back into your own network?
One of the clients I worked with had had a very high amount of medical imaging exams that they were sending out the door. Through this type of work we were able to focus that back and saw the early immediate gains back into the medical imaging department within that organization.
So, they were able to drive additional revenue in the millions of dollars because they were actually able to say OK, we can actually start focusing on getting our own patients in a timelier manner. The imaging department in that particular organization had a reputation within the organization's clinics and everything that they couldn't get – the doctors couldn't get patients in. It just took too long to get their MRI or their CT or anything like that.
And so through having a focused effort on improving accessibility and schedules and things of that nature and then remarketing back out into the clinics themselves, we were able to kind of self-direct those patients within that same network. They keep them within the network. It just ends up improving the continuity of care overall.
Rick Shepardson: And the improving continuity of care and improving productivity and revenue for that imaging department, it ends up producing benefit for all the providers and the patients and organization at large, right? Yeah a lot of far reaching impacts here. I think we'll probably get into a discussions on referrals again in the future. I have this in my crystal ball here. I think that this is a good discussion on provider accessibility. I really appreciate the time that you were able to to spend here today.
Andy Palmer: Yes, certainly. It's something I am very passionate about, and I think that there is a lot of opportunity in a lot of organizations to really focus on this type of thing.
Rick Shepardson: We've done this before a couple of times right?
Andy Palmer: Yeah, once or twice.
Rick Shepardson: It's great so I would love to do it again. Appreciate the time.
Andy Palmer: Thanks Rick. Thanks for having me.