In the following interview, Mark Murray, MD, MPA, Principal of Mark Murray and Associates, outlines the benefits — for patients and clinicians — of minimizing delays and improving continuity of care.
What is primary care access and why is improving access such an important goal?
People use the term “access” to describe a number of things: 1) lack of access or availability of care, usually for a population of patients or geographic area; 2) insurance coverage; or 3) expanding hours of operation to improve access to care. No matter how we use the term, however, the fundamental functional issue is delays in getting care.
Improving access is a euphemism for minimizing delays and it should be a fundamental goal for all practices. We should avoid all delays, except those governed by patient physiology, because they lead to:
- Suboptimal acute, chronic, and preventive clinical care
- Poor patient satisfaction
- Added cost, including the cost of rework, redundancy, triage, and waste (e.g., in the form of no-show appointments)
Increasingly, insurance companies and others reward care providers for meeting specified clinical goals or waiting time performance standards. With that in mind, it’s important to understand that providers cannot fully optimize clinical care unless you address both continuity of care and delays. Practices can’t provide the best care, or get primary care medical home certification, unless they reduce wait times and delays and improve access. Balancing demand for services with an appropriate corresponding supply eliminate delays.
What is “advanced access” and what are the keys to achieving it?
The term “advanced access” is often misunderstood and misused. Let’s start with some fundamentals about the potential models we can use to match primary care demand to supply:
- Saturated: A practice completely fills the physician’s appointment schedule, with either minimal or maximal amounts of triage and sorting. If a patient calls needing a same-day appointment, the practice offers an appointment with the primary provider as an “over-book” or with another clinician, if available.
- Carve-out: A practice leaves some appointment capacity available for same-day needs.
- Access by denial: In order to provide space in the appointment schedule, a practice allows no patients to make future appointments. If a patient calls and there are no openings available that day, they can call back the next day.
- Advanced access: Demand and supply are measured and balanced. Plans are developed to deal with variations in the practice's schedule. The patient backlog is eliminated. Instead of filling the schedule, the practice manages each day’s demand on that day. The goal is to minimize delay.
How do providers eliminate a backlog of patients waiting for appointments?
I’ll use an analogy. My brother has a credit card debt of $5,000. Every month he gets a new bill. He pays off the interest, plus any new charges accrued. Next month, he’s still got a bill of $5,000. That’s his backlog. In order to pay off his credit card balance, he’s got to pay off the interest, any new accrued charges, plus the existing $5,000 accumulated debt.
Appointments are like that. Physicians have to pay off their appointment debt by working harder for a temporary period of time until they see all the patients waiting to be seen. Once they eliminate the backlog, implementing advanced access practices helps keep demand and supply in balance.
Does improving access create more work for practice staff, or make it easier to provide better care in a manageable way?
I’ve seen it over and over again — improving access increases physician and staff satisfaction.
I worked with a group of 12 physicians who committed to continuity — that is, they made changes to improve continuity of care, going from rarely seeing their own patients to almost always seeing their own patients. This change resulted in much higher staff morale and less burnout.
When we design work environments in which clinicians see their own patients for the vast majority of their encounters and understand who their patients are — and patients are not waiting or complaining about waiting — then the burnout we hear about so much these days dissipates.
Providers and staff feel better about the work they’re doing. They says things like, “This is what I trained for. This is why I went to medical school.” When we improve access and minimize delays, what Dr. Christine Sinsky calls “joy of practice” starts to come back.
How does a practice “commit to continuity”?
Committing to continuity means intentionally using a system that supports each physician seeing his or her own patients. That doesn't happen all by itself.
In the different health care system designs, some don’t allow practices to commit to continuity. For example, with the saturated model, if my sick patients call in, the scheduling staff have to say, "Mark’s schedule is full. He can’t see anybody else today. Would you like to see somebody else?" That’s a system designed for discontinuity.
When I worked at Kaiser Permanente, we did a study that found that when patients saw a familiar doctor — not their own, but still familiar — the likelihood of coming back within two weeks was twice what it was when patients saw their own doctor. When patients saw a total stranger, the likelihood of coming back within two weeks quadrupled. Those are the consequences of not committing to continuity. In other words, when patients could see their own doctor, they didn’t feel the need to come back right away, but they did when they couldn’t.
Do you have an example that illustrates why improving primary care access is so important?
I worked with a group of physicians reimbursed by capitation that reduced costs by 25 percent, primarily by committing to continuity. They also reduced ED visits by 21 percent and urgent care utilization by 50 percent.
I worked with another group whose mammography rates were 14 percent — only 14 percent of women who should get mammograms actually got them. They right-sized their patient panels, committed to continuity, and got rid of backlog and the mammography rate improved to 82 percent.
How does a practice right-size their patient panels?
To right-size a panel, you need to determine the correct number of patients assigned to each care team within the practice. The number is derived from an equation: demand = supply.
Demand = (Number of clinician's patients) x (Number of visits those patients are going to use)
Supply = (Number of days the clinician works) x (Number of patients the clinician can see in a day)
Panel = (Number of days the clinician works) x (Number of patients the clinician can see in a day) ÷ (Visit rate [i.e., visits per patient per year])
Too often, physician practices will just make up a number that sounds good to them. But if the panel is too big, the practice can’t manage the work and patient care is going to suffer. On the other hand, if the panel is too small, then the practice can’t create enough value.
Determining the appropriate patient panel size, committing to continuity of care, and minimizing delays are just some of the most effective changes primary care practices can implement to improve access and patient and provider satisfaction.
Mark Murray, MD, MPA, is Principal of Mark Murray and Associates and faculty for IHI's Transforming the Primary Care Practice seminar.
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Team-Based Care: Moving from Ideas to Action
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IHI resources on optimizing the care team to improve primary care access