Solve Access to Health Care or Pay the Price

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Improving access to care has steadily risen as a top priority of health care organizations. While physicians, other members of the health care team and health care organizations all strive to provide the best possible medical care, gaining access has become increasingly problematic.

The term "access" and all the components associated with it have become one of the key topics in cardiovascular management, and problems with access plague many health care organizations.

While resolving the issue of timely access can be complex, unsolved issues relating to access can have deleterious effects on not only the quality of care provided but also the perceived care experience, and ultimately the financial performance of the organization.

Expectations of acceptable wait time has evolved substantially, and varies depending on the health care consumer as referring entities, specialists and patients may all have a different definition of timely access to care.

Furthermore, in situations where a health care organization is negotiating directly with a business entity, one of the first metrics examined frequently is access and availability of both primary care and specialty providers.

Ultimately, any organization or practice delivering care wants to ensure they have the appropriate and necessary access capacity to meet the needs of their referral partner – be it other physicians, urgent or emergency care centers, or the public at large.

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Outpatient practices typically have a variety of patient queues with varying needs. There are established patients in need of routine follow-up, patients with urgent concerns, new patients looking to establish care or seeking expert consultation, and others.

Decreasing the variety of patient queues will create positive benefit as the queue theory indicates that minimizing the number of queues can facilitate throughput.

One component when measuring access is the effective utilization of provider resources. There is an inverse relationship between the length of delay for an appointment and the likelihood that the patient will not show.

This is particularly true for new patients who have not yet established a relationship with a health care provider; yet, new patients are essential to the viability of any organization due to the generation of substantial downstream revenue in procedural, supportive and potential long-term care needs across an organization.

Cardiology Magazine ImageJaewon Ryu, MD
Cardiology Magazine ImageThomas H. Lee, MD, FACC

Jaewon Ryu, MD, and Thomas H. Lee, MD, FACC, discussed these issues and noted that when the lead time to an appointment increases from 6 to 12 days, the no-show rate will double. Inversely, they also discussed the misalignment when physicians are paid for productivity and hence rewarded for clinic schedule templates that are completely full, with acute patients having to be worked in.

The authors stressed the misalignment that was present in fee-for-service vs. value-based models; however, this can still occur if the organization is being paid in a value model but the physician compensation model is predicated on physician productivity.

Additionally, it is well established that the longer the delay to appointment availability, the more likely that the patient will seek care in a more expensive setting, such as the emergency department.

Patients with chronic illnesses (such as heart failure) who have a lengthy delay prior to their first appointment are significantly more likely to be readmitted with heart failure when compared with those who are seen within the first seven days after discharge.

The increase in avoidable costs for care received in advanced care settings are punishing for a variety of quality programs, and particularly so when patients are enrolled in an Accountable Care Organization.

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When considering the financial impact of poor utilization of provider resources, the cost can quickly add up. An average compensation for a cardiologist can be more than $290 per patient contact hour, and coupled with lost revenue of a minimum of $153 per encounter, the cost of a cardiologist having an unfilled template can be financially catastrophic.

You must consider similar issues when not properly utilizing advanced practice providers (APPs) and their lost revenue can exceed $87 per encounter in addition to their hourly compensation.

Access issues can also result in both short- and long-term shifts in referral patterns or "referral leakage." If there is limited or unavailable access when needed for an individual patient, this could stimulate a referral to an alternate provider or network. Long-term referral pattern shifts are likely to occur if a competing organization provided excellent care in the eyes of the referring provider.

A myriad of internal issues can contribute to problems with access. If referral management is not efficient throughout the process, there will be associated cost with delays or potentially a decline in referrals.

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Receiving inappropriate or incomplete referrals from affiliated practices, as well as issues with the receiving cardiology staff not processing referrals appropriately, can cause costly delays to access and care.

Processing issues can occur if there are too many appointment types (new consult, established, long visit, hospital follow-up, etc.), limitations on templates, or a lengthy triage processes, which can limit flexibility and therefore access.

Open access template management has been demonstrated to improve scheduling flexibility and hence improve both access and provider efficiency. Template management inefficiencies continue when established patients are scheduled well in advance, filling up the templates that then subsequently limit new and urgent patient access to the physician schedule.

Inappropriate utilization of the care team often compounds this issue.

Care team models or team-based care in outpatient settings are generally comprised of APPs, clinical support staff (RNs/MAs) and administrative staff. The care team works alongside a physician or group of physicians to support the full care experience.

If there is inappropriate utilization of an organization's care team, the result will cause limited access to an organizations most costly asset: the physician.

Improving the care team functions and allowing each individual to complete a higher-level work within their scope of practice is one of the most powerful means to improve access.

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This can be structured multiple ways with clinical support staff efficiencies while the patient is in the clinic (patient education, rooming expansion, team-based charting, etc.), as well as when the patient is not in clinic and contacting the office with questions (medication refill programs, nurse triage, pre-visit planning, RN or APP lead clinics, etc.).

Allowing APPs to see new patient visits vs. only working as extenders is also a factor in access. Having all providers work at the top of their license can improve financial performance while also maximizing access for the organization. APPs can also be highly effective in performing outreach in rural areas and expanding the organizations market share within their service area.

The care team concept should also be examined from a global prospective. Improvements in the utilization of APPs in the hospital – such as having APPs discharge patients or see uncomplicated stable patients admitted to another service – can free up physician time and be redirected to improving access in the outpatient setting.

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This article was authored on behalf of the CV Management Publications Workgroup by Jesse E. Adams III, MD, FACC, cardiologist at Baptist Health in Louisville, KY and Ashley Wishman MS, CEP, system director of medical specialty care at Bozeman Health in Bozeman, MT.