Easy scheduling, quick access will make providers more competitive
In much the way 401k investment plans forever changed retirement benefits and led to the realignment of the financial industry in the 1980s, a concept called “consumer-directed health care” (CDH) appears poised to transform the way health care is delivered. While increasing numbers of employers sponsor consumer-directed insurance plans that emphasize high deductibles with a safety net to cover long hospitalizations, the government offers health savings accounts (401k-type plans for health care) to make the transition easier for employees.
Baby boomers already prone to comparison-shop — reviewing a hospital’s quality indicators and the price of routine procedures — are expected to pay even closer attention when a larger percentage of the money being spent is coming directly out of their own pockets.
CDH advocates contend, as employees take a more active role in purchasing their health care, providers will be forced to compete for their business, resulting in dramatically reduced costs for similar quality and significant improvements in service levels.
As hospitals prepare for this new dynamic — with the goal of increasing service levels and giving these new consumers what they want — the attention inevitably turns to access management. An article titled “The Role of Access Management in the New World of Consumer Directed Healthcare,” posted recently on the web site of SCI Solutions, suggests that hospitals and health systems focus on how to better market their services, target their customers, and navigate comparisons regarding trade-offs between cost and quality, and offers eight questions to help providers assess their CDH readiness.
Hospital Access Management asked several leaders in the access field to respond to those questions and discuss their implications:
• How easy is it for the physician-referral population to do business with my hospital?
The University of Arkansas for Medical Sciences (UAMS) Medical Center in Little Rock offers referring physicians, as well as internal ones, the option of completing an on-line scheduling form to request an appointment, says Janet Lynn, director of patient coordination. “That form gives us the patient and physician demographics, the diagnosis, and the requesting clinic,” she notes. “If they provide an e-mail address, the system will automatically e-mail them back with an appointment.”
Staff also call back to confirm the information, Lynn adds. At present, “there are very few referring physicians who opt for that service,” she says, noting that most use the toll-free number that is provided for appointment scheduling. One of the things UAMS Medical Center does to make that process easier, Lynn says, is to have enough schedulers so there is very little chance a caller will be placed on hold or have to wait for someone to pick up the call. “Our average answer delay is consistently 10 seconds or below,” she says. “Our goal is 10 seconds, and we pretty much stay within that.”
Schedulers get basic information — name, date of birth, telephone number, provider, and reason for the appointment, Lynn notes. “The difficulty we have is appointment availability. Our physicians serve three hospitals, do research and teach, and their clinic time is limited,” she explains. To help alleviate that situation, physicians are asked to increase the number of patients they see in a half-day clinic from six to seven.
At Swedish Covenant Hospital in Chicago, says Gillian Cappiello, CHAM, senior director of access services and chief privacy officer, “we make it as simple as possible [for referring physicians] with one advertised number.”
Providers who offer a single number, however, should make sure employees answering the calls have the skill level and resources, such as databases, to appropriately respond to or direct callers, Cappiello points out. “If [physicians] schedule surgery, they shouldn’t also have to call admitting.”
Swedish Covenant recently put together a physician orientation manual that outlines need-to-know information such as hours of admitting, key service lines, and contact people for each department, she adds.
• How many phone calls does it take to get an appointment?
“It should take only one — for patients and physicians, but if a patient is calling, [the scheduler] is only as good as the information the physician provided,” Cappiello says. If, for example, the physician didn’t included the ICD-9 code, she notes, a callback might be required.
“We try to schedule with the patient as best we can, have them assume we’re finished, and then follow up with the physician if necessary,” adds Cappiello. “On rare occasions we may need to call the patient back — if we discover the person needs a two-hour, rather than one-hour, appointment. Ninety percent of the time it’s one call.”
At UAMS Medical Center, the appointment staff can schedule on-line in its scheduling system for about half the hospital’s clinics, Lynn adds. “For some clinics, we gather the demographics and forward the appointment request to the scheduler for that area. Then there are other clinics that we can only transfer the caller,” she says. “We do get complaints that it takes too many calls to get an appointment,” Lynn points out, primarily because of the need for some specialties to pre-screen appointment requests.
“We have 14 people who schedule appointments [in a central location], but they are not allowed to schedule for all of our clinics. When someone calls for a neurosurgery appointment, for example, schedulers take the information and forward it to that clinic, Lynn explains. “Physicians are trying to ensure that the patient needs to be referred to their clinic, so they may want to look at the medical records before scheduling.” The process can be frustrating for callers who provide information and still have to wait for another step, she adds.
• On average, what is the lead time to get a radiology exam done?
Routine radiology is an on-demand service at the University of Pennsylvania Medical Center-Presbyterian in Philadelphia, says Raina Harrell, business administrator for patient access. Streamlining the process is the practice of allowing certain physician practices to have block time in the radiology area so they can bring patients in more quickly, she adds. “Orthopedics is one of our high-referring [specialties], so their patients take priority in those rooms,” Harrell says.
The practice also allows the hospital to get other patients in more quickly because space has been allocated for the high-demand practices, she notes. “Our schedule moves faster than some of the other hospitals because of the way patients are organized with that block time.”
Same-day or next-day appointments should be provided, Cappiello says. Timeliness with this kind of service is particularly important, she adds, because of the recent profusion of freestanding radiology centers. “The physicians want [their patients] in as soon as possible. If we can’t fit them in, they’re going to go somewhere else.”
With a routine procedure, patients might be willing to wait, but if they have a busy schedule and can only come before work, they have choices,” she adds. “There are dialysis centers, and cancer centers all over the place. [To be competitive], we really have to make [care] available at their convenience.”
Another trend that is providing patients with more choice in providers — at least in her area — is a shift from HMOs back to preferred provider organizations (PPOs), Cappiello notes. Her personal experience, she says, is that HMO plans are no longer significantly less expensive when one takes into account discounts and the ability to go to a specialist without a referral from a primary care physician.
• Can our customers interact 24-7 with the hospital over the web to schedule services, complete mandated, seemingly redundant forms, and pay their copays or outstanding balances?
Swedish Covenant patients can pay copays and outstanding balances on-line, Cappiello says, but at present, scheduling over the web is available primarily for classes offered by the hospital. While noting that the ability to schedule services — particularly, routine procedures — on-line certainly is coming, she points out that, even with mammograms, on-line scheduling will present challenges. “People may say they want a routine mammogram, but when you ask them for a diagnosis, it may turn out that they forgot [that something else was needed], or their grandmother had a history that turns it from screening to diagnostic, which is a whole different [procedure],” notes Cappiello.
“A lot of our testing now is so [complicated], and physicians are not very good at indicating exactly what they want,” she adds. “The scheduling system would have to be very sophisticated, or there are few kinds of appointments that would qualify.”
At UAMS Medical Center, patients and physicians, as described, can request appointments 24-7 by filling out an on-line form, Lynn notes. “We [make] that appointment, and the person receives an e-mail [confirming it].”
• How well are we positioned to compete with retail health care storefronts in malls and specialty radiology centers?
One of the major issues that comes into play here is cost, Cappiello points out. “Our charges are typically higher than some of those places, largely because our overhead is more.” On the other hand, her hospital offers benefits such as an automatic 50% discount for self-pay patients, she adds. “Hopefully, that would take care of [cost competition], although it’s not why we’re driven to do it,” she notes. “Part of our mission is to serve the uninsured.”
• Can our patients go directly to the point of service without having to interact with the registration system?
While patients must have some interaction with registration — certainly demographic information must be obtained at preregistration — those details can be taken care of over the phone, by mail, and perhaps in the near future, via the Internet, Cappiello says. At Swedish Covenant, she notes, patient interaction with registration is virtually seamless, thanks to a code that prints on departmental schedules and on lists provided to lobby services personnel, indicating the patient’s registration status.
Although anyone at UPMC-Presbyterian who is scheduled also is preregistered, that amounts to only about 40% of the patients, Harrell says. “We have a huge population of walk-ins.”
At UAMS Medical Center, Lynn says, “some of our customers are being preregistered before they come to the clinic. Others have to be registered on arrival. In some of the clinics, the point-of-service coordinators are the ones who do the registration.” These employees, who report to clinic management, “are almost financial advisors,” overseeing copay and billing issues, she adds. Patient access staff now preregister patients for five UAMS clinics, Lynn notes, and “our goal is to do that for all the clinics.” That goal may be realized with the implementation of a new scheduling system in about 18 months, she says.
• Do we know if we are going to get paid for the services we are about to render?
“More than 95% of the time, we do [at Swedish Covenant],” Cappiello explains. “If the patient is scheduled, we pretty much know [if we’re going to be paid]. We don’t know if [the patient] is urgent or an add-on. We usually have a pretty good idea and start working on it right away, but we’re not going to delay services for that small percentage we can’t figure out.”
The answer is yes at UPMC-Presbyterian, says Harrell. “We verify all patients coming in for services prior to rendering services.”
At UAMS Medical Center, that certainty of payment does not exist at present, says Lynn, noting that a large percentage of uninsured patients is the greatest obstacle to reimbursement. “Because we’re a state hospital, we’ve always been perceived as a free clinic.” There are plans to implement a program whereby patients will be made aware at the time of scheduling that a payment will be expected, she adds.
• Do we offer patient self-service capabilities such as payments and registration through the web and kiosks?
Swedish Covenant patients can make payments through the web and through a secure phone system, Cappiello says. Patients also may go on-line to print out preregistration forms and then send the completed forms through the mail, she notes — a method that is used primarily by obstetrical patients. With most other patients, registration staff initiate a preregistration phone call, Cappiello says, “because we have the [notice of their upcoming service or procedure] from the physician before they have a chance to call us.”
While UPMC-Presbyterian currently is not offering on-line or kiosk options for payment or registration, Harrell says, she is eager to take steps in that direction. “Our patients are looking for the best route to get to health care,” she adds. “They’re always asking, ‘Is there something I can do in advance?’ or ‘Can I do it myself?’ Any hospital that makes that available will definitely have an advantage.”
In much the way 401k investment plans forever changed retirement benefits and led to the realignment of the financial industry in the 1980s, a concept called "consumer-directed health care" appears poised to transform the way health care is delivered.
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