Better patient access as a key to healthier populations

In the traditional “fee-for-service” world, patient access optimization - namely, improving the ability to convert patient demand into booked encounters – has served as an effective means for health systems to improve revenue (and patient experience).

Have empty capacity in the health system? Fill it as best as possible and optimize for measures like surgical yield and specialist utilization to maximize margins in those high-value areas. Access is also typically linked to referral retention, in that the likelihood of a referral staying within a defined provider network improves when the referral base can find available slots in the system.

That same “blunt instrument" of patient access can also play a critical role in the value-based care world, where limits to access can have significant negative consequences from a cost and outcomes perspective. In a model where risk management is king, and proactive and timely access to care can mean the difference between shared savings or severe financial loss, optimizing capacity is essential.

One might consider the coarse analogy of how airlines manage first-class seat inventory. The generally understood logic is that airlines are best off saving those first-class seats for customers who will pay list price, and only open them up for complimentary upgrades when a specific time window has passed and the likelihood of a full-price customer coming along is low. In a similar vein, imagine a risk contract member base in which you have Steve, an athlete in his 20’s who is experiencing pain in his back after lifting weights, and Malcolm, a 65-year-old chronic diabetic with a history of heart failure and hip replacement surgery calling in with the same complaint. You’d want to have saved that “first-class seat,” or earlier appointment slot, for Malcolm, to see the higher complexity case as quickly as possible versus Steve (assuming he is generally healthy) who might be able to wait a couple of additional days or see a physical therapist instead of a physician.

Seemingly basic algorithms like this for optimizing access and load-balancing appointment usage are rarely part of care management programs, despite the potential for significant improvements in the management of high-risk patient cohorts. Patient access technology that addresses this, as well as the use cases below, can play a key role in helping population health management programs improve outcomes and reduce financial risk:

Ability to search for appointments with a clinically-appropriate provider, within an appropriate time horizon relative to the patient’s acuity and clinical complexity – provider networks are often riddled with dozens of different scheduling systems or clunky scheduling tools that don’t support dynamic searching for providers and appointments. Patient access software can support the care coordinator’s need to identify providers with appropriate access without compromising on the specificity of the clinical care the patient needs. A viable solution should be able to take into account the patient’s clinical needs at the diagnosis or procedure level, additional clinical context (e.g., previous test outcomes, additional symptoms, or active medical therapies), and personal preferences (e.g., geographic proximity or whether the office can provide a translator). It should also be able to surface recommendations automatically for providers with either immediate availability (if the situation is emergent), access within a short time window (for urgent situations), or access within a reasonable horizon (for less urgent situations). This should be possible across all practices in the network, regardless of the scheduling systems in use, so health systems can more optimally balance network supply with patient demand.

Ability to schedule appointments electronically across multiple practices and systems, by both the practice and the patient – many care coordination efforts stumble when they get to the actual appointment booking step in the referral process. Without the ability to “self-serve” by directly scheduling or electronically requesting appointments, a care coordinator might spend hours making dozens of calls to multiple practices to check for availability and waiting for callbacks – not to mention potentially multiple calls to the patient as well. Anecdotally, this process can take days to weeks, and sometimes the patient ends up not getting the needed appointment at all. In a risk-bearing model, this can have significant financial and clinical ramifications – the patient’s condition could worsen in the period of time she is waiting to get access, and some proportion of those cases might end up emergency rooms or seeking care out-of-network with a provider at another system. Patient access technology can be a key enabler here by streamlining the point-of-referral booking process across practices and scheduling systems, as well as engaging the patient through digital communications and self-service appointment management tools, to reduce the potential of a patient deteriorating or seeking care out-of-network.

Ability to manage data about the provider network dynamically – population health management is inherently a data-driven discipline, but oftentimes, even the most seemingly straightforward data – that which describes who the providers are in a given network, along with their clinical, insurance, location, and availability information – is poorly managed and becomes a barrier to access. An effective patient access solution gives health systems the capabilities to manage and, more importantly, maintain provider data in a cost-effective manner. Governance is a key dimension to data management, as the ability to maintain and review the data in a decentralized manner improves the agility of the network to respond to change. The types of information that a software system can capture and leverage in its algorithms and business rules logic can also contribute to stronger decision making and more precise patient triage. For instance, in addition to accurate demographics, practice information, and schedule availability, provider quality measures for specific procedures or diagnoses can help inform whether a given provider might be better for one patient or another. An effective patient access software solution can bring the power of this type of information to the point-of-referral and enable more precise decision making.

Finally, patient access technology can help health systems enable their providers and care management staff to practice at the tops of their license, ensure that patients receive the right level of care, and manage care delivery costs effectively. Tools that enable providers to define their clinical focus areas at a detailed level, such that they receive high-quality referrals into their practice, can contribute to the achievement of the so-called Quadruple Aim; in addition, tools that engage patients in their care are likely to create a better patient experience while also improving access to timely and appropriate care, a critical component of effective population health management.

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