New Rules for Managing Patient Access Demand Creativity, Common Sense…and Call Centers

When the dust settles and the destiny of the Patient Protection and Affordable Care Act has been decided, healthcare organizations will begin to operate within "the new normal." Are these organizations prepared? How does one prepare for the most profound healthcare legislation of our generation? This question has been posed so often that it is has become essentially rhetorical.  

No matter what becomes of the reform legislation, it's clear that new rules are being formulated now and that executives are accepting the need to adapt. Nowhere is this more evident than in the area of demand management, where healthcare systems attempt to regulate access to healthcare services through onsite and outsourced contact centers. To be sure, the process of demand management has changed dramatically in the past few years. No longer is this practice a form of "one size fits all."

A silver bullet for ACOs?

The contribution that call centers can make under any healthcare reform scenario is only now being understood. While many organizations are scrambling to line up dance partners or to create their own ACOs, those with competent call center operations have an opportunity to immediately apply those assets to improved performance under the PPACA.  

Consider the example set by Optum, the health services technology division of UnitedHealth Group. Through an innovative partnership with Tucson Medical Center and more than 250 independent area physicians, Optum has helped to form Arizona Connected Care, a new ACO in the Tucson market. Optum, which includes a contact center as the centerpiece of its portfolio, is part of the risk-bearing entity in this partnership, making up a three-legged stool that will contract with multiple payors. Optum intends to use the call center to manage patient flow by offering appointments, nurse triage and navigation support to the plan's initial 7,500 members.  

Swiss Army knife of call centers

What of call centers that lack the capacity of a national operator? How can organizations leverage their local call center assets? If there is insufficient time or capital to create a bona-fide center that can support the demands of an ACO, then there are certainly many commercial operators that offer stop-gap solutions. NotifyMD, a patient communications company, offers everything from traditional functions (appointments, appointment reminders, messages and answering services) to literally serving as a facility's main switchboard. At Martha Jefferson Hospital in Charlottesville Va., NotifyMD has placed their own employees side-by-side with hospital operators, while also providing the ability for calls to overflow to one of their national centers during peak periods of demand. Pages overheard in the hospital corridors may actually originate from the company's call center on Long Island, NY.

SMS/text messaging, offered by a handful of national operators, is increasingly employed to remind patients of appointments or to reach certain cohorts of patients based on risk profiles. Among patients who have opted in for text messages, a reminder can be sent for seasonal flu vaccination, mammograms or other routine screenings. In settings where influenza can spread rapidly, such as college campuses or among pediatric practices, this application offers the leverage necessary to address the burgeoning need among those suspected of contracting the flu, while preserving capacity within the call center to deal with more complex concerns.

Seeing red

Where does an organization start to assess its current capacity and future needs? It is instructive to consider the experience of El Rio Health Center, also in Tucson. After receiving feedback from the community that the system created barriers to entry that began with their call center, the organization embarked on an ambitious journey to create "Patient Communications 2.0," or "PC2" and set about building call center capabilities well beyond their current state. Starting with a vision statement that patients will be offered open access to the health center's resources, the system proceeded to document the current state of all services accessible by phone. This resulted in some 30 "value streams" that were subject to further scrutiny for improvement opportunities. Value streams allow an organization to distinguish valuable (color coded in green) from wasteful (red) process steps.  The method is derived from the very rigorous Six Sigma methodology and, with the support of a consultant bringing such experience, the organization is experiencing a culture change (see photo below).

"We quickly found this is very hard work," recalls Nancy Johnson, the system's COO. "But what we are learning about our existing capabilities and future potential is invaluable as we chart a course for the future." El Rio plans include replacement of their existing telephony infrastructure to take advantage of a range of sophisticated features (including how long patients can be expected to remain on hold, with the option to abandon and be called back), as well as a partnership with a nurse triage service to augment and improve their capabilities until their own institutional growth catches up with community demand.

El Rio staff including Evan Hatchell (back to camera), Lakiya Perkins (pointing) and Aimee Stone (observing) examine their value stream.

 El Rio staff including Evan Hatchell (back to camera), Lakiya Perkins (pointing) and Aimee Stone (observing) examine their value stream.
El Rio staff examine one of about 30 value streams to reveal opportunities for improvement in their call center workflow.  Red dots indicate process steps that offer no value to patients

A thin red line

Why are such proactive investments in call center capability necessary? First of all, there is the practical matter of compliance. In California, for example, the Department of Managed Health Care has introduced "Timely Access Guidelines," effective this year, that require contact centers to conduct triage and screening within 30 minutes. California is the first state to set limits on the time it takes for HMO members to receive telephone-based care. The National Committee for Quality Assurance requires contact centers offering email support to respond within 24 hours.  Add to this the accrediting agency known as URAC ( which includes a series of other requirements for certification, including "average seconds to answer" of 30 seconds or less, abandonment under 5 percent and callbacks within 30 minutes. URAC requirements are increasingly finding their way into RFPs for contact center services.

Beyond compliance and accreditation, however, administrators are becoming sensitive to all aspects of the member experience, recognizing this goes beyond the time they spend in the provider's office, or on the phone with member services.  Indeed, this experience legitimately extends to all points of contact across the continuum, and for many members their contact with call centers is the predominant form of interaction they have with their hospital or health plan.

Savvy administrators also realize that there is a potential false sense of security in looking merely at averages and understand that the spread (also referred to as the standard deviation) is equally important, as it calls out the very best and worst performance over the period being measured. It is often the case that organizations have not formalized their contact center, but instead distribute calls across a variety of clinics and departments. This leads to inconsistency in how calls are managed, perceived chaos as staff try to balance response to phones with members in their presence and significant variation in the member experience.

From red tape to blue oceans

Much has been written about the impact of "blue oceans," based on the best selling book by the same name. Blue oceans differentiate competitive business strategies from the more traditional "red ocean" approaches of industry that view their marketplace dynamics as a given, and compete for share at the expense of one another. In a blue ocean, companies seek to make competition irrelevant by creating new markets and new consumers.

For those in search of blue oceans, however, the process can be frustrating. Blue oceans call for a significant reduction in costs of production while simultaneously enhancing the value perceived by consumers. How does one accomplish this in the delivery of healthcare services? While Netflix, Southwest Airlines and Home Depot are proof that blue oceans exist, developing one in the parochial field of healthcare is another thing altogether.

Enter Keona Health, a start up company that has revolutionized telephone-based triage. By leveraging the time of the patient, Keona's call center software is the closest thing to self-service triage ever seen in the US market.  Patients enter their chief complaint online and engage in a brief automated intake interview, which automatically establishes the acuity level for nurses working either in a call center or clinic. High acuity patients are called back first, unless they need to be seen in urgent care, in which case the system immediately returns information on the closest site for care. Keona has demonstrated a 50 percent reduction in unit costs because nurses do not need to create documentation (the patient does it), and a significant percentage of calls never even reach them. Patients receive immediate feedback from the system and often a quick follow up call from a nurse, rather than having to wait in queue for "the next available representative." Contact centers find they can dramatically reduce their recruitment efforts since the application significantly increases the capacity of the existing workforce.

Double down

Its timely for organizations to reassess their capabilities in demand management and to consider the impact that a competent call center can have on their competitive position going forward. "Buying down" a long ASA or high abandonment rate through outsourcing can be as sensible a strategy as paying points on a mortgage. Adding a self-service capability may appear "bleeding edge," and yet many members would prefer this to waiting on the phone for what seems like an eternity. The idea is to create an immediate improvement rather than hoping for more favorable conditions down the road. And as an estimated 32 million uninsured wait in the wings for access to the healthcare system, these strategic moves cannot come a moment too soon.

Ian R. Lazarus is Principal at Creative Healthcare (, founded in 1998. CHC provides healthcare performance improvement training, tools and technologies, with specialization in the support of medical call centers.

More Articles by Ian Lazarus:

Six Sigma, 10 Years on: Was "the Promise" Realized?

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