Once again, we find ourselves stuck between a rock and a hard place.
Increasingly, providers are being pressured to improve access for our patients, which we certainly think is a good thing. We want our patients to come in, whether it’s for their annual physicals, for ongoing routine management of their chronic health conditions, or for acute issues best handled in the primary care office instead of ending up in the emergency room. And we want to get them in to see us, not someone else.
Continuity is always preferred, as it’s much better for patients to see a provider they know, just as it is much easier for us as providers to see a patient we know. Studies of practices have repeatedly shown that both patient and provider satisfaction go up as continuity indices increase, and patients get less testing done, less over-diagnosing, and less overprescribing.
But when each of us, at the beginning of a practice session, is faced with a full schedule, and we know that our day is not going to end until all those patients have been seen, all those notes have been written, all those phone calls have been answered, and all those patient-portal messages, texts, and emails have been responded to, then how can providers be asked to do more?
Increasing patient volume won’t work
Recently, we’ve been tasked with increasing our patient volume in our practice, essentially trying to increase our volume by 30 percent. This is to satisfy the never-ending appetites of access and finances.
Now, if you think about it, our patients are already frustrated by how little time we get to spend with them. They feel rushed through the office visit, as do we. Neither of us gets to discuss everything we’d like to.
If doctors and other providers are asked to squeeze more patients into the day, it’s only going to create more havoc, more chaos, more pandemonium. And the patient who is late is going to make the schedule that much more tumultuous, and the wait times will only increase, leading to more frustration and shorter tempers.
And it’s hard to ask our trainees, the interns, and residents seeing patients as part of our practice, to just up their volume, as this seems to value service over education.
While there is learning to be had in every patient care case they see, when we come to them with financial concerns and say the practice needs to see more patients and we need to overbook their schedule, it can feel petty and somehow misdirected.
Focusing on the no-shows and walk-ins
But what if we could do something about our no-show rate, and just make sure that the right patients came in, those that are scheduled to see us, and that there was an outlet to handle overflows and urgent patients who might walk into the practice? Providers with protected time, telemedicine, and other types of care opportunities might help fill some of these gaps.
But wouldn’t it be amazing if everyone on the schedule as of 8:00 a.m. at the start of business was really truly definitely confirmed to be coming in that day, and had everything arranged to make their care come off as smoothly as possible?
Yesterday, for example, 58 patients never made it to their appointments, including about a dozen initial visits and a large handful of patients recently discharged from the hospital.
A similar number called up and were able to reach our practice and canceled their appointments, but same-day cancellations are problematic in that it’s hard to find someone right at that moment to fill that suddenly open slot.
Lots of missed opportunities to provide care.
Still, we did see over 300 patients, and each one of those interactions was invaluable, both for the patients, for the providers, and even for the bottom line of our practice.
How do we make this better?
Higher-tech reminders …
For years we sent out reminder cards for appointments, and recently we switched to another system that sends out long, complicated letters with convoluted instructions, but neither of these seemed to make much of a difference in whether a patient showed up at our practice for their scheduled appointments.
As we move toward more sophisticated technological solutions, our institution hired a company that calls all of our patients, starting 48 hours in advance, to confirm their appointments. This week, for the first time, I got a look at the report on how this was doing, and was shocked to discover that 90 percent of the attempts to reach patients were unsuccessful.
For many patients, the phone numbers we had listed were incorrect. Many patients just weren’t home, and the system cannot leave a message on voicemail, since that would be a HIPAA privacy violation (“Don’t forget you have an appointment with Dr. Pelzman tomorrow to get that STD treated!”).
And I suspect that a lot of patients use caller ID that probably identifies this phone call as coming not from me — their trusted primary care provider — and is probably flagged as spam.
My own home phone is pretty darn good at caller ID, and it is always a relief when that computerized voice says, “Call from Spam, New York.”
I think more sophisticated technological solutions should help, and we are exploring using the electronic portal to remind patients about upcoming appointments, as well as giving them the opportunity to cancel or reschedule. And I’m hoping that we can take advantage of the fact that almost everybody seems to have a smartphone these days, and to be able to send an active ping to patients reminding them about their appointment, as well as giving them options of texting us back to let us know when they are not going to make it in.
… and some lower-tech solutions
We also need to work with live human beings here in our practice to participate. All team members should fill our practice schedule with the maximum number of patients who want and need to be seen. We need to make sure they’re coming; we need to make sure their safe transportation is arranged; and we need to make sure they get here on time and have the necessary information for us to see them.
Just the other day I watched as someone arrived in our practice and was told that their insurance had lapsed, and they would be billed for the visit that day. They were asked whether they wanted to pay up front, and they didn’t know how much the visit would cost or whether they would be reimbursed by their insurance company, and so it all fell apart.
So where does the sweet spot lie?
Rather than overbooking 4 or 5 patients onto a morning schedule of 12, based on the assumption that 30 percent will not show, why not just book those 12 and then do everything you can to make sure each and every one of them is coming in?
We need to do a better job of making sure everyone who wants to get here can get here, everyone can get the care they need, and no one gets turned away. We need to balance the need for patients to be seen, the need for providers to be busy without being overwhelmed, and the need for everyone to get the right care they need at the right time, in the right place, from the right provider. That will solve our no-show rate, our access problems, and also hopefully help balance the books.
That should make all our lives 130 percent better.
Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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