A provocative headline got my attention recently. It proclaimed that patient portals are "largely unused." It caught my eye partly because it didn't sound all that plausible -- and because taking such a headline at face value could be unhealthy for your businesses, dear clients and friends of Capko & Morgan. I decided to dig into the matter. The article text actually mentioned that 37% of patients have recently used portals. Could the author actually believe that 37% utilization is trivial? That seemed to be what they were saying, yet it's hard to imagine they believe that. (Would a 37% decrease in salary leave one's pay "largely" unchanged?) Perhaps, you may be thinking, this was just a forgivable, inadvertent misuse of "largely." But I tend to think not. This type of exaggeration is just too common in modern media, even in our world of the business of healthcare. I tend to think the headline intended to sensationalize. Yet even if that wasn't the intention, it's still not a benign error, which is why I'm calling it out. Mischaracterizing portal adoption has a hidden cost Clients often tell us they've held back on technologies that could make their practices more efficient because they're concerned patients won't use them. But that thinking usually means practices miss out on significant benefits, since the tools they delay adopting (or forgo altogether) could make interaction easier for patients or make their practices more profitable (or both). This tendency to hesitate has been especially true for patient portals, and it's often very costly. Somewhere along the way, the idea took hold that portals aren't worthwhile unless nearly every patient uses them. But this is not true. It's not even close to true. If even a small percentage of patients regularly uses a portal, those patients will benefit -- and their physicians will save time, too. (And that's strictly on the clinical side. Portals have the potential for even more dramatic benefits on the payment and administration side, even when utilization is very low.) What's more, relative to other recent technologies, portal adoption is arguably not that
In a typical medical office layout, there’s a front door that’s used by patients and a rear door (or staff entrance) for employees. Of course, this can be quite convenient, especially when connected to employee parking. But an interesting consequence of this configuration is that physicians and managers never experience the reception area from the patient’s perspective. Next time you head out of the office during the day, come back in through the front door. Have a seat in the reception area. Are the seats comfortable? Are there enough of them? Are they spaced appropriately or too close together? (Imagine yourself sitting next to a sneezing flu patient if you need helping deciding.) If there’s a television, is it audible, but not too loud? Are there recent magazines on hand, or raggedy old ones from last year? What does the front desk activity convey to people waiting? Do patients look impatient – like they’ve been waiting too long? If so, does anyone behind the front desk seem to notice? In our consulting engagements, we almost always have comments on how the reception area can be easily and inexpensively improved. But you don’t need consultants to figure this out. It’s easy to self-diagnose – and the upside on improving could be huge. Patients start deciding how they feel about the quality of the care they receive the moment they walk into the office. Even ill patients will feel better about their visit – and their experience in the exam room – when their first moments in your practice reassure them they’re in a welcoming, professional, and caring environment. Patients view their entire practice experience as their “care” – not just the 15 minutes they get with a clinician. An inviting reception area is a cost-effective way to reinforce your practice’s caring attitude – and get the patient visit off to a strong start.
One of our previous clients decided to move on from her group practice to set up her own practice. After being in town for just a few short years it would be important for her to have a following of loyal patients. For this reason, I decided to research how patients were rating her, and discovered her average rating with several major sites was a 4+ stars. Sounds pretty good, doesn’t it? I decided to dig deeper and read some of the reviews. 4 out of 5 had wonderful things to say, but the one critical rating was brutal and contrary to the glowing comments other patients made about this fine doctor. The strong negative comments by this single reviewer related to his experience with the front office. I suspect this could have been avoided if the front office team took pride in their work and understood that a major part of their role is to greet each patient properly and make sure their needs are met, as well as preparing them for the visit. Such comments as: “I waited an hour in the reception and was completely ignored; the receptionist was rude and acted inconvenienced; I was a new patient and no one seemed to care” reflect a patient that feels discounted and gets upset before ever being escorted to the exam room to meet the physician. Unfortunately, it’s not rare to hear patients complaining about the way they are treated at the doctor’s office and how poorly it compares to their experience at Starbucks or their local bank. It’s time for medical practices to implement some training standards that put patients first. It starts with creating a culture where physicians and managers believe their staff is their number one customer. Staff will only treat patients as well as they are treated by their superiors and the respect and care they are given. A practice will not thrive unless the work environment is one of respect and appreciation – and it starts at the top! Hire good people and treat them right Be selective in who you hire. The
Chronic problems at the front desk are a way of life for medical practices in most specialties, and it seems there to little effort resolve these problems. The painful reality is that the demands on the front office are often unrealistic. It’s unlikely that the staff can handle a high volume of inbound phones calls at the same time they are helping patients check in and out, updating patient information, collecting patient payments, scheduling follow-up appointments, and answering patients’ myriad questions – and do it all well. No wonder a recent MGMA survey reveals that the front office has the highest rate of staff turnover in the typical medical office! Front office staff is set up to fail These tasks all demand more attention and time than your front office staff have. Since there is never enough time to give any task the attention it requires, front office staff is set up to fail. There is never enough time to get the work done and give patients the service they expect and deserve. It’s time to get realistic about front office workflow Start by understanding the distribution of tasks in the front office. Instead of front staff being generalists that all do same thing, divide the work in a way that makes each of them an expert and gives them sufficient time to manage their workload. Study the job description(s) for members of the front office team and diagnose workflow. Include the team in the process of improving the function of the front office. Compare the written job descriptions to the actual tasks and responsibilities of the position. Probe staff to get their input about workflow and what happens during the work day that makes the job difficult and demanding. Map out the current workflow, identifying bottlenecks and what causes them. Seek to divide and group tasks sensibly. For example, doesn’t it make more sense for patient inbound calls to be taken away from the front desk, so the patients can be checked in and out without interruptions that irritate patients or allow patients to slip out the door without
(c) Barclays PLC* A few days ago, the ATM turned 50. The first ATM in the world debuted in London in 1967; we got our first one in the US in 1969. Wow! I bet that the ATM has been around longer than many of you reading this. It's hard to imagine a time when this technology wasn't on every street corner. Yet when the ATM was first introduced, it was slow to catch on. In fact, it took about 30 of those 50 years for the ATM to be used by 2/3 of consumers -- and even as recently as 2013, more than 10% of consumers still had yet to pick up the ATM habit. The ATM's slow-but-steady path to everyday use got me thinking about technology in the medical practice. Technologies to connect patients and practices, especially on the administrative side, have emerged at a fantastic pace in the past few years. But many practices we've worked with have hesitated to implement them, for fear that the majority of their patients won't use them. Some practices that have implemented, say, a patient portal or online scheduling, have been disappointed because only a portion of patients seem excited to use it. "Laurie," they say, "we tried that. Only 20% of our patients used it. It was a failure, so we abandoned it." But when the ATM was first introduced, the adoption rate was much slower even than a 10% or 20% utilization your practice might see on its new payment portal or online schedule. So why didn't the banks give up? After all, implementing an ATM network is a massive, risky, very costly undertaking. So why were the banks undeterred by their meager initial results? And what can we learn from it for our own technology initiatives? The key is to focus less on the people who don't try the technology, and more on the people who do. For every one of those few customers who used the ATM in those early days, the bank could declare a victory. The consumer who wanted to use an ATM
Recently, the check-in automation company Phreesia invited me to write an ebook on one of my favorite topics: the patient-centered practice. It's called "Beyond Five-Star Reviews: Why the Patient Experience Matters, and How to Improve It," and it's available free with registration -- just click on this link. The idea of being more patient-centered and creating a better patient experience attracts more controversy and confusion than it should. The bottom line is that being more patient-centered fits with clinical goals as well as business ones, because it may help patients become more engaged and more receptive to clinical advice. "Patient-centered" is not about chasing positive reviews, and it's not about being patient-led. It's about understanding the patient perspective and communicating that you do, while also maintaining your practice's clinical integrity and mission. And it's about focusing on administrative processes patients interact with every day that can make your practice more or less welcoming and convenient for patients. The ebook contains some ideas that any practice can implement to improve the patient experience. I hope you'll check it out -- download it here.
A new study from the University of Florida found that patients' rudeness towards their physicians can have a "devastating" impact on medical care. Patient rudeness may play a critical role in medical errors, which by some analyses are now the third leading cause of death in the US. The Florida researchers determined that patient rudeness causes more than 40% variability in hospital physician performance. (By contrast, poor judgment due to lack of sleep led to a 10-20% variance.) The reason for the huge variance is that despite intentions to 'shake it off,' experiencing rudeness disrupts cognition, even when physicians are determined to remain objective. The researchers found that key cognitive activities such as diagnosing, care planning, and communication are all affected -- and the effects last the entire day. The study suggests that patients need to understand the potential for rude behavior to undermine their care, even when clinicians try their best to be patient and understanding, and even when the rudeness is driven by understandable frustration. But I think the results are also a reminder to practices to try to limit patient frustrations in the first place. Doctors often bear the brunt of patient rudeness when aggravation and anxiety boil over, even though most of what bothers patients happens before they even see their physician. Because administrative issues are frequently the source of dissatisfaction, it's possible for practice staff to prevent or ameliorate many blow-ups. Doing so may help patients have more productive visits with their clinicians, while also helping to protect the practice's reputation and maintain a pleasant work environment for the entire team. If you're concerned about emotional patients disrupting your practice, here are a few ideas to consider: Evaluate, minimize your wait times. A long, unexpected wait in reception is a sure-fire source of patient frustration. When it happens in your practice, is it a rarity or SOP? If running significantly behind is an everyday occurrence your practice, consider a review of your scheduling processes, to come up with a schedule that is attainable. And make sure your front and back office staff are working together
This amusing television ad from Cigna is bound to attract a bit of attention from fans of Grey's Anatomy, Scrubs, House, ER, and MASH. It's cute. If you recognize any of these tv docs, you'll likely enjoy it. And it has a message that can help patients get more out of their insurance, and help your practice, too. The gist: we'll use our skills as fake doctors to urge you to go see real ones for preventive services. Nice recommendation. Preventive services give your practice a reason to reach out to patients -- a gentle way to remind them your practice cares, and to keep them engaged. And it's a great way to get more use out of the EHR your invested so much time and money in implementing. With the deductible reset just over one quarter away, if you're a primary care practice (or other practice that offers a qualifying preventive service), you might also think about booking annual check-ups in Q1 of 2017. If your practice is among the many that see a slowdown in Q1, your patients will appreciate being able to come in when it's less busy. And deductible-free visits are good for your cash flow and cash-strapped patients' wallets after the holidays.
As you may know already, I've been working on a series of papers on Medicare's chronic care management reimbursement program (CCM) for the Medical Product Guide. (Click on 'resources' after visiting the Medical Product Guide link if you're interested -- they're free.) Talking to practices that have already started working on CCM, along with others that have held back, has been a learning experience. The ability to take on CCM quickly depends a lot on your current practice set-up and, especially, your EHR. On the current set-up side, if you're working on or already have set up a medical home (PCMH), and have one or more case managers in place to support it, you may find it easy to use the same staff structure for CCM. Your case managers could become the coordinators for CCM as well -- perhaps personally contacting patients and doing the other care management tasks that contribute to the required 20 minutes per month for billing. Perhaps there will be overlap between the PCMH and CCM that could be beneficial -- if, for example, you're looking at a similar mix of conditions, that might allow for some standardized communications or tracking tools. Or perhaps you could add a group visit program that would serve patients from both programs. (A group visit program wouldn't contribute to the CCM monthly time requirement, since that's strictly non-face-to-face time, but it still could be well received, and fit with the patient engagement goal of the program.) On the other hand, if your practice hasn't yet taken on PCMH, CCM could be a stepping stone. Many primary care practices believe they're already doing many of the tasks that are meant to be compensated by CCM -- they're just not tracking them, and they haven't had a way to bill for them, either. That last problem is expressly addressed by CCM -- the key is solving the former problem of tracking. EHR vendors vary dramatically in this area. Some have already created dedicated modules that allow for templates for clinical staff contacts to be tracked, and for the time to be calculated. Others
ZocDoc just published a compelling new article and infographic pulling data from a survey they recently conducted about patient behavior. The data put a quantitative face on what many of us have been observing anecdotally and reading in blog commentary online -- namely, that patients are increasingly reluctant to see their providers, and costs and scheduling challenges are a big part of why. One tidbit that jumped out at me, since preventive care is something I consider a win-win opportunity for practices and patients, is that 80% of patients surveyed were putting off preventive care. Some of the key reasons ZocDoc found were the inconvenience of keeping an appointment during work hours (in fact, more than 40% said they would likely cancel because work took priority) and the inconvenience of making an appointment in the first place. Preventive care should be increasingly valuable to patients as deductibles and co-pays have grown across all types of health plans. But many patients don't realize that this is usually a way they can take advantage of their coverage without cost-sharing. Many other studies have shown that patients are more confused than ever about their health plans; this puts the burden upon practices to fill in the information gap (but that also spells opportunity for practices that do so). Are you doing all you can to engage patients and encourage them to take advantage of their preventive care benefits? Some ideas to consider: Consider offering an early morning or early evening appointment option at least once per week -- or even occasional Saturday appointments Look into online scheduling to allow patients to book appointments without having to make a call during work hours Use EMR list tools (remember them from MU?) and your portal to reach out to patients who haven't had preventive services or are overdue Put information about what's included in preventive care -- and why it's important -- on your website
A key factor in the patient-centered movement gaining traction is the Affordable Care Act and its intention to improve population health and reduce healthcare costs in the United States. This is expected to be accomplished through improved patient satisfaction, coordination of care and better clinical outcomes. The Patient-Centered Medical Home (PCMH) is viewed as a path to accomplish this and CMS is offering financial incentives to primary care practices that become recognized as a PCMH. The idea of PCMH was developed through a consortium of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. Together they developed joint principles for the PCMH including the provision that each patient would have their personal physician and their care would be directed by the practice, ensuring care was coordinated and/or integrated as deemed appropriate with an expected level of quality, safety and enhanced access, as well as establishing appropriate payment for these efforts. There is national growth in practices achieving recognition as a PCMH with the front-runner of recognition programs being offered by the National Committee for Quality Assurance. In 2011 NCQA’s standards increased to include guidance on developing chronic care management programs, enhancing patient engagement and improving patient outreach, and aligning with EHR and the new healthcare Meaningful Use criteria. NCQA’s program promotes goals to: Improve the patient experience Recognize clinicians’ efforts Provide confidence for purchaser: value for money spent on quality care CMS led the pack with financial incentives for the PCMH, but other payers have also emerged with bonus and payment systems that recognize the PCMH, improved outcomes and patient satisfaction In 2013 NCQA announced the Patient-Centered Specialty Practice recognition program. The development of this program was motivated by the discovery of reporting discrepancies between referring physicians and specialist. The PCSP program is designed to improve communication and access. Yes, there’s a lot of buzz about the focus on being patient-centered and improving the patient experience, but the programs are only growing in importance. If you haven’t already done so, it’s time to get information, make the commitment
Would you believe that failure to collect consistently and adequately at the front desk can actually create a negative impression of your practice's patient service? And that skipping financial conversations to keep the focus on patient can actually backfire? Money conversations can be hard for all involved. And, when a practice staff is very focused on patient-centered service, it can seem counter-intuitive to emphasize financial details -- especially when patients are ill or injured. But, ironically, not being clear about financial terms and not collecting appropriately can actually cause your patients to feel worse about your practice than a conversation about money ever could. When you fail to collect adequately at the front desk, your patients will receive a bill -- and, if you are waiting for their insurance to pay its portion first, that bill may not even be mailed until a month or more after their visit. By that time, the patient may have forgotten all about the visit -- and never even considered they would owe a balance, especially if staff never mentioned that they would or provided an estimate. It's likely they've already allocated their monthly budget to other things. And maybe they're confused about the bill -- and now will spend time trying to figure it out, perhaps on hold with their health plan, or feeling they have to call your biller. All of this adds up to aggravation. And if they don't believe (or don't want to believe) they owe the money, they can become quite angry with your practice. Nobody likes unexpected bills. Properly estimating patient costs and alerting patients that they have financial responsibility for all or part of their service is one of the kindest things you can do for them -- and critical to maintaining a positive relationship. Learn more about front desk collections at my upcoming webinar on 9/23/14 (9AMPST/12PMEST) -- sponsored by Wellero and hosted by Physicians Practice. It's free! Register here.
On July 8th Medscape presented a thought provoking discussion with three primary care physicians titled “The Good and Bad of Patient Satisfaction Measures.” This fuels the ongoing debate of the value and scores as part of physicians’ payment for their patient services -- a subject of keen interest to me. In March 2012 the Archives of Medicine published a study conducted by Joshua Fenton, MD, MPH, and colleagues at the University of California, Davis. The study analyzed data from more than 50,000 adult patients, indicating the most satisfied patients were 12% more likely to be admitted to the hospital and their healthcare and prescription drug costs were 9% higher. One of the most interesting findings to the study’s readers was that the report revealed more than 26% of these patients were more likely to die. What a startling fact! One of the strengths of this study was its nationally representative sampling. The findings were derived from the assessment of satisfaction based on 5 measures from the well-known CAHPS survey, emergency department visits and inpatient admissions. The tension between patient satisfaction and patient outcomes and cost savings continues two years after the study was released. There is discussion about whether physicians motivated by payment structures based on patient satisfaction are influenced in the ordering of diagnostic studies typical treatment standards in order to keep patients happy. An article in appearing in Forbes on July 21, 2013; “Why rating doctors is bad for your health” by Kai Falkenberg discusses this issue. "THE MATH IS NOW SIMPLE FOR DOCTORS: More tests and stronger drugs equal more satisfied patients, and more satisfied patients equal more pay. The biggest loser: the patient, who may not receive appropriate." When physicians are pressured and financially incentivized to keep patients happy an ethical dilemma occurs and some physicians succumb to appeasing patients by ordering tests they might not otherwise order. Forbes reported that the South Carolina Medical Association asked its members whether they’d ever ordered a test they felt was inappropriate because of such pressures, and 55% of 131 respondents said yes. Nearly half said they’d improperly prescribed
The idea of 'nudging' in behavioral economics gets a lot of play in healthcare. But most of the attention is on the public health/patient side -- i.e., how to persuade patients to do what public health administrators believe is best for them. These ideas often focus on negatives and can be controversial -- prompting cries of 'nannying' and 'coercion.' But some fascinating recent research by Balaji Prabhakar of Stanford shows that positive, incentive-based nudging can help reduce traffic and even help people have a little fun at the same time -- and it got me to thinking, should we take a look at this type of positive nudge as a way to improve medical practice workflow? If you have a minute, take a look at this brief article on the Stanford Business School site -- it explains how Prabhakar was inspired to try to help address the insane traffic problem he observed when visiting Bangalore on business. A commute of 9 miles to his client's office in one of the busier areas of the city took employees an average of 71 minutes! Prabhakar thought a scheme of incentives might help persuade employees to commute at off-peak times. His goal was to apply a key insight from his work as a computer scientist: that reducing peak load by just 10% would dramatically improve other metrics like wait times. Could this insight also help your practice? Prabhakar used an interesting incentive to encourage off-peak commuting: lottery entries. Each early arrival earned an entry into a weekly lottery -- so more early arrivals meant more chances to win. This was a positive approach (unlike some nudges that are perceived as punishments), and it helped make the program fun and created weekly excitement. So what if your practice wanted to reduce congestion -- say, due to late-arriving patients? What about rewarding patients who arrive on time with a thank you and a scratch ticket or other small gift? And are there times of day that are harder to book at your practice? Perhaps a little reward for patients that can come in at those less
In 2013 NCQA rolled out the Patient-Centered Specialty Practice, PCSP, Recognition Program to distinguish specialists that achieve specific marks with: Developing and maintaining referral agreements and care plans with primary practices; Providing superior access to care (including electronically) when patients need it; Tracking patients over time and across clinical encounters to ensure patient care needs are met; and Providing patient-centered care that includes the patient, and when appropriate, the family or caregivers, in planning and setting goals. The motivation behind the PCSP program began when reporting discrepancies were identified between referring physicians and the specialists they refer to. For example, referring doctors claimed that between 25 and 50% of time they were unaware if the patients they refer are actually seen by the specialists. Another discrepancy was the specialist claiming they sent consult reports 80% of the time, but the primary care physicians state they receive this information only 60% of the time. With the PCSPs intent on improving care coordination and communication between specialists and their primary care physician, managing chronic and acute conditions across continuum of care will be better accomplished. The PCSP program also evaluates medication management, test tracking and follow-up and information flow over care transitions. This recognition program is expected to result in a better patient experience and improved outcomes.
The Patient-Centered Medical Home is so much more than just a payment innovation -- it's an idea that appeals for clinical reasons to so many physicians and practice managers, who were already aiming to provide the higher level of care-coordination and patient engagement that is the foundation of the PCMH. But many small practices we work with have been nervous about the hurdles for certification -- is it too much for a solo or two-physician practice to take on? A recent AAFP blog post offers a wonderful idea for smaller practices daunted by the prospect of tackling the PCHM checklist on their own: form an informal network with other, like-minded practices in your area, and divvy up the research and learning. What a great solution -- and a great way to expand your connections with other professionals in your community. Read about it here.
The buzz about being patient-centered is not just hype, the patient-centered movement is very real and there is much to gain. The primary premise of the patient-centered movement is that by building stronger relationships with patients they will be healthier. Healthier patients mean a healthier population. A healthier population reduces healthcare expenses which have soared in the United States over the past few years. Reducing these expenses is a goal that health plans are increasingly willing to pay practices to help achieve. Understanding what it means to be patient-centered is a complex process as it intends to recognize patients in terms of their own social worlds. This means throughout the patients’ healthcare experience they should be respected, listened to, informed and involved in their care. It is believed that shared decision-making results in better compliance and reduces health risk factors. Focusing on individual patient’s needs an applying evidence-based medicine is meant to improve the healthcare population. Insurance companies, recognizing these factor,s are in the process of implementing financial incentives and bonus structures based on key elements that improve the delivery of health care and manage costs by reducing complications and emergency room visits, and by complying with best preventive practices. Your intentions to be more patient-centered can be reached by: Strengthening the patient clinical partnership; Promoting communication about things that mater to the patient; Helping patients know more about their health and healthcare needs; Facilitating patients’ and caregivers involvement in the patient’s care; and Setting metrics to measure improvement. Being patient-centered is rewarding for your practice in so many ways: happier patients, potential financial upside, and stronger relationships between providers and patients. All of these themes are discussed in greater depth in my and Cheryl Bisera’s new book: The Patient-Centered Payoff (click the link to see the book's page on Amazon).
Will your practice be taking part in this eight-state pilot? Requirements will include EHR, flexible hours, various preventive and individualized care activities. http://www.innovations.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/index.html