Over the past years there have been increased demands on healthcare organizations to improve accessibility and quality while simultaneously lowering costs. There are limited studies on strategies to meet these demands.
The objective of this study was to improve accessibility for outpatient appointments, achieve increased show rates and meet demands of access without negatively affecting cost, quality, and physician time. This study is based on medical specialty, and involved a clinic's specific patient population. We focused on new patient volume to see the effects through increased clinic volume, access, and revenue, as well as, increased downstream ancillary volume and revenue. An initial survey was conducted with 182 participants new to the Gastroenterology clinic to understand the existent discrepancy between appointment times and preferences. The data was used to adjust physician schedule templates to increase access. A follow-up survey was conducted a year later with 166 new patients to measure success. After implementing our strategy we have seen an annual patient volume increase of 26.3%. We expect a continued annual growth rate of 12.1% for our clinic. Over the course of this study, no show rates decreased from 18% to 11% and satisfaction with appointment times has increased by 35%. Overall Press Gainey scores have increased, indicating no negative effects on practice operations or quality of care. Improvements to patient access can be made by rearranging physician templates based on medical specialty, involved clinic's patient population, and patient preferences, without any adverse effects to cost, quality, and physician time.
Introduction
Over the last few years, the healthcare landscape has changed drastically; due largely to the implementation of the Affordable Care Act (ACA), the evolution of the use of electronic medical records (EMR) through the HITECH Act, a progressive shift from inpatient to outpatient care, and the trend of hospital mergers and acquisitions. These changes have created several challenges that healthcare organizations must now face, like increased operational costs, decreased reimbursements, and a greater need for increasing patient volume. The ACA in particular calls for healthcare organizations to increase the quality of care, reporting of quality metrics, and accessibility, while decreasing the cost per capita (Adamopoulos, 2014) . These demands, along with the continued evolution of EMR, contribute to increased operational costs (Hall, 2014) . The decrease of inpatient volume over the years due to changes in payment models from the ACA, research, and technological advances are forcing healthcare organizations to shift their focus from inpatient to outpatient care in order to counterbalance the negative shift in revenue and reimbursements (Kutscher & Evans, 2013) . The trend of hospital mergers and acquisitions also contributes towards decreased revenue for smaller community hospitals and private practices (Rosenthal, 2014) . As larger healthcare organizations gain greater negotiating power and larger referral bases through mergers and acquisitions, smaller community hospitals and practices lose their negotiating power with payers, thus decreasing their revenue (Ellis & Razavi, 2012) . Further pressuring healthcare organizations, is the demand for increased health care accessibility. Due to the 2014 individual mandate, there has been an influx of newly insured patients, which has contributed to the demand of healthcare services exceeding the current supply available. In light of these changes and challenges, healthcare organizations are compelled to consider new methods to meet these demands.
At our organization, we pride ourselves on offering our patients high quality care at reduced costs. In order to combat the ever-changing healthcare world, we worked to develop strategies that will help us maintain our overall goals. When developing such broad strategies, one school of thought would be to increase outpatient access and provide services to a greater volume of patients, thus increasing access and generating more revenue. However the question still remains how to accomplish this without negatively impacting cost, quality, and physician time?
Currently, there are limited published works and data available to effectively manage these demands, making it difficult for healthcare administrators to appropriately strategize. At the Gastroenterology clinic, we had considered two approaches to help increase access and decrease no-show rates: overbooking, and rearranging physician schedule templates according to the specifics of their medical specialty and patient preferences. Overbooking would have been the simplest method to increase patient access and revenue; however there are potentialoperational repercussions that could occur with this approach. It is important to consider the effect overbooking will have on quality of care, patient experience, and physician burn out before implementing this method. For example, if overbooking was used as part of the normal practice for a clinic and all, or most, patients showed up; patients could experience extended wait times, physician burn out, and decreased quality of service. Overbooking may even increase operational costs due to increased costs for staff overtime. Therefore, we came to the conclusion that this approach would not be an optimal solution for the Gastroenterology Clinic. Our second approach, to rearrange the physician templates according to specifics of medical specialty and patient preferences, was hypothesized to increase patient access and decrease no-show rates. This would be done by realigning physician templates with times that would be more appealing or convenient for their patient population. Additionally, rearranging physician templates would not lead to increased costs or require the usage of additional resources. We then devised our strategy around this concept and collected data from our patients to identify preferences and trends to be incorporated in the new physician schedule templates.
Methods
Our study was geared towards new patients for several reasons: to grow the volume of new patients, to attempt to improve the patient payer mix, and to capitalize on increased new patient volume in order to generate downstream volume and revenue through increased follow-up volume, which in Gastroenterology specifically, means an increase in procedural referrals. There has been a significant increase in the number of newly insured patients due to the individual healthcare mandate; therefore we saw this as an additional opportunity to focus on improving access. Our goal now is to have the ability to offer appropriate, as well as sooner, appointments to patients per treatment plans. Furthermore, a study indicated that the average wait time for a patient to be seen by a specialist can range anywhere from six to eight weeks. During this period of time, the patient's condition can worsen, thus the need to improve access and expedite the provision of healthcare services to our patients.
In this study, an initial patient survey consisted of 182 participants chosen from five categories: new patients age 60 and over, age 59-35, age 18-34, patients located within 2 miles of the clinic, and a random selection. This survey was conducted to gather qualitative data from our new patients seen within the last six months of the survey. The survey contained short, open-response questions for the patient to express their experience at our Gastroenterology clinic, with focuses on appointment time, ease of making an appointment, how long they had to wait for their given appointment, if they were satisfied with the time they had received, timeliness, if they had to rearrange their schedule to make the appointment, what was their most ideal time during the day for an appointment, and their overall experience. The data gathered focuses on appointment booking experiences and was used to investigate patient preferences and trends. The data allowed us to rearrange the physician schedule templates appropriately. A follow-up survey of 166 new patients, chosen using the same criteria as the initial survey, was conducted twelve months after the complete implementation for the new physician templates. Data from this survey was used to reevaluate the strategy and adjust the physician templates as needed.
Findings
Using the trends found through our patient survey, we were able to identify "hot spot" times, or times that more patients preferred to have appointments. We identified a certain set of times as hot spots: 7:30-9AM, 10:30-12AM, and 2-4PM, specific to this study and the Gastroenterology practice. Using these hot spot times, we worked with physicians to redistribute their patient time slots on their templates, in order to reflect patient preferences and ensure that we had the maximum new patient appointments available during these hot spot times. In addition, we structured the templates so that a new patient appointment will be available each hour throughout the day. The breakdown of new patient appoint time preferences are shown on Figure 1.
A follow-up survey was conducted to re-evaluate whether the new physician templates were conducive to patient preferences. Past patient volume and Press Gainey scores were also compared with current numbers to gauge the effects of our implementation. The follow-up study indicated similar patient time preference schemes. It also indicated a 35% increase on patient satisfaction with the appointment time received, compared to the initial survey. Patient volume had increased by 26.3% over the last 12 months, Figure 2 depicts the overall new patient volume growth since the implementation of our strategy. Given current trajectory, we expect to see a continued growth rate of 12.1% per year afterwards. Our no show rates also decreased throughout the course of this study. In fiscal year 13 our no show rate was 18%, this decreased to 16% in fiscal year 14, and again in fiscal year 15 to 11%. Our Press Gainey scores have greatly improved, particularly in the category of accessibility. The results indicate that patient accessibility has increased, along with drastically improving overall patient experience, while still maintaining the same high quality of care and low costs.
Conclusion
Our study shows that rearranging physician schedule templates to be more conducive to patient preferences can help healthcare administrators meet the demands of an increasingly complicated healthcare setting. This method not only increased patient accessibility to necessary healthcare services, but also decreased no show rates. Thereby, increasing overall health of our patient population and optimizing staff time. This strategy allowed the same quality of care to be maintained, while not increasing costs. Furthermore, physician time was not increased, as additional time slots were not added to increase the number of patients seen, unlike the practice of overbooking. This initial pilot study has been successfully rolled out, with minor alternations, to other specialty practices. The increasingly complex world of healthcare forces administrators to look for other methods to improve cost, quality, and access. Through the use of this strategy, improvements to patient access can be achieved while still providing them with the highest quality of care at no additional cost.
About the author:
Ashish Buttan BDS, MBA is a seasoned healthcare administrator / strategist specializing in areas of patient access, revenue cycle operations / productivity and clinical program development. Currently working as Service Line Administrator for Neurosciences at Children's Hospital Los Angeles.
Dr. Harmony Allison, MD, MPH is a renowned Gastroenterologist in the New England market. She leads the clinical operations for the Division of Gastroenterology at Tufts Medical Center, Boston, in her role as Clinical Director.
Howard Chan is an aspiring healthcare leader, pursuing his Masters of healthcare Administration from Suffolk University, Boston. His interests lie in areas of process improvement and patient access.
1 Adamopoulos, H. (2014, September 29). Hospital Ratings: What the shift from inpatient to outpatient means for performance measurement. Retrieved September 16, 2015, from https://www.beckershospitalreview.com/finance/hospital-ratings-what-the-shift-from- inpatient-to-outpatient-means-for-performance-measurement.html
2 Hall, S. (2014, February 13). Hospitals don't factor in full cost of EHR implementation. Retrieved September 30, 2015 from http://www.fierceemr.com/story/hospitals-dont- factor-full-cost-ehr-implementation/2014-02-13
3 Kutscher, B., & Evans, M. (2013, August 10). The new normal? Shift to outpatient care, payer pressures hit hospitals. Retrieved September 16, 2015, from http://www.modernhealthcare.com/article/20130810/MAGAZINE/308109974
4 Rosenthal, A. (2014, July 6). The Risks of Hospital Mergers. Retrieved September 16, 2015, from http://www.nytimes.com/2014/07/07/opinion/the-risks-of-hospital- mergers.html?_r=0
5 Ellis, J., Razavi, A. (2012, June 08). Mergers are sweeping the healthcare landscape: Retrieved September 18, 2015, from http://www.healthcarefinancenews.com/blog/mergers-are- sweeping-healthcare-landscape
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