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    By Sara Turley, MBA, chief of staff, Rush University Medical Center; Michelle Hirschman, MBA, service line administrator, Rush University Medical Center; and Steve McMillen, MHA, senior manager, ECG Management Consultants

    Access is a strategic priority for medical group leaders, but they often lack the ability to measure their performance. Leaders juggle a variety of static reports about time to appointment or third next available, but this information is rarely actionable and often inaccurate.

    Instead, access should be evaluated through the lens of supply and demand. In this case, demand represents unique patients seeking new patient appointments, and supply indicates the practice’s capacity to accommodate appointments within a patient’s desired time frame. By consistently evaluating a practice’s journey to equilibrium between supply and demand, it can achieve greater access, which leads to growth, financial sustainability and patient satisfaction.

    In this equation of supply and demand, medical groups have more control over supply, as measured by provider capacity. Therefore, practices should begin their access journey by properly assessing and evaluating their providers’ capacity to see patients. Outlined below are three key tactics for evaluating and improving capacity to drive an access strategy:
    • Analyze provider clinical time
    • Examine the relationship between clinical time and productivity
    • Optimize key capacity drivers.

    Analyze provider clinical time

    Medical groups tend to focus on benchmarking provider compensation and productivity; however, it can be challenging to understand whether a provider is working to his or her full capacity. This is particularly relevant for specialists whose clinical work occurs in a variety of settings. Analyzing provider capacity is the crucial step to ensuring access is available. Prior to considering the recruitment of additional providers, assess whether supply can be increased using existing resources.

    To understand current provider capacity, compare each provider’s actual worked hours to contracted or expected number of hours using the following steps:
    1. If not already written into provider contracts, set a standard expectation for the number of patient-facing hours a full-time clinical provider should work, adjusted for each provider’s clinical effort. For example, your institution may determine that 32 hours per week is consistent with a full-time provider, allowing for one hour of administrative time per half-day block of patient-facing time. Establish a standard number of workweeks per year, such as 47, which allows for five weeks of time off annually.
      These metrics enable you to calculate that a full-time clinical provider should be scheduled to work 1,504 hours per year (32 hours per week x 47 weeks per year). Similarly, 0.90 clinical FTEs (CFTEs) would be expected to work 1,354 hours per year (1,504 hours x 0.90 CFTEs).

    2. Quantify the actual hours worked by each provider. Depending on the specialty and type of work, the effort required to calculate this will vary. Include time spent in the clinic, performing procedures or surgeries, reading imaging studies and providing inpatient coverage. A primary care provider who works exclusively in a clinic setting would be straightforward to quantify, as Figure 1A demonstrates. A procedural subspecialist who spends time at multiple clinical locations may be more complex to quantify, as illustrated in Figure 1B. While calculating these hours, it is important to account for all actual hours worked, rather than “planned” hours, which may be skewed by underutilization or inaccurate templates.

      Once actual time worked is calculated, compare it to the hours each provider is expected to work; this is referred to as a worked-to-expected (W:E) analysis. The W:E analysis serves as a quick guide for administrators to understand opportunity areas to improve capacity at the individual or programmatic level. It is also a useful tool in beginning discussions regarding provider time spent in clinical settings, including the trends over time. Run these analyses routinely (e.g., monthly or quarterly) to adjust for changes in capacity, demand or schedules.

    Examine the relationship between clinical time and productivity

    Once a W:E analysis has been completed, compare it to the provider’s productivity, as shown in Figure 2.

    Comparing an analysis of hours to an analysis of productivity (e.g., wRVUs as a percentage of industry median) can reveal opportunities to improve provider capacity, and thus, patient access. In comparing these data points, one of four scenarios will emerge, as depicted in Figure 3:

    1. Alignment of W:E and productivity: Often a provider’s productivity performance is related to the number of clinical hours he or she works, as outlined below.
      1. W:E hours are low and so is productivity (scenario 1): In this scenario, a provider’s work hours should be increased to align with his or her CFTE, and the assumption is that productivity would also increase.
      2. W:E hours are high and so is productivity (scenario 2): This is likely the ideal scenario and may not involve any action; however, leadership and the provider should be aware of risk of burnout and proactively intervene as appropriate.
    2. Misalignment of W:E and productivity: While it is reasonable to assume that a provider working sufficient clinical hours will have appropriately aligned productivity metrics, this is not always the case, as outlined below.
      1. W:E hours are low but productivity is high (scenario 3): Providers in this situation may be highly efficient, or they may be performing more high-yield activities than their cohort, internally or at external organizations. Examine these providers in the context of their colleagues to understand whether any practice nuances account for this misalignment of work hours and productivity. For example, a pulmonary provider who subspecializes in sleep medicine may require a modified productivity benchmark.
        This scenario may call for realigning benchmarks or spreading work more evenly among members of the specialty. If a provider’s clinical hours are below the expected target, clinical time should be increased. In most medical groups, high productivity should not give providers a free pass to work fewer hours than what they are contracted.
      2. W:E hours are high but productivity is low (scenario 4): Examine in further detail how the provider’s clinical time is being spent, and ensure proper capture of clinical activities, including billing. Some common areas of misalignment include:
        • The provider is scheduled for clinic but blocks time as unavailable.
        • There is low demand, and the provider has unfilled slots.
        • The provider’s visit durations are too long for their complexity.
        • The provider’s time is not being billed properly (e.g., undercoding, open charts, unbilled encounters).
        • An aspect of the provider’s time is not being counted (e.g., imaging reads are performed but not billed).

    Optimize key capacity drivers

    Even providers who are productive and working sufficient hours should focus on drivers that affect the practice’s overall access strategy. Key components that can help providers understand practice capacity and access include new patient ratio, visit lengths and conversion rates.

    New patient ratio

    Productivity and access metrics are not always in alignment, and sometimes highly productive providers may be spending time on activities that don’t support the practice’s access mission. For example, a provider who prefers to obtain wRVUs by treating two established patients instead of one new patient in the same amount of time is not prioritizing access. Provider schedules should be designed with the proper new patient ratios in mind, with dedicated appointment times for new patients. The ratio of new to return visits will vary: surgical and procedural practices should see up to a 50% new patient ratio, while medicine practices will see less, and primary care will see closer to 10% to 20% to align with the longitudinal care they provide.

    Visit lengths

    The duration of appointments also has a significant impact on access and provider productivity without affecting the hours a provider works. The average visit length will vary by specialty and the amount of support provided by nurses, residents or advanced practice providers working alongside the provider; however, decreasing visit times will have a direct and positive impact on access. For example, if a provider typically schedules new patient visits for 60 minutes, reducing each visit to 40 minutes will allow for 50% more visits to be added.

    Conversion rates

    In addition to new patient ratios, the ratio of new patients to key procedures or surgeries is an important access metric. For example, heart surgeons who are expected to perform 200 open-heart surgeries per year will benefit from knowing their conversion rates between new patients and surgeries. If two new patients are seen in the clinic on average for every one surgery, this surgeon would need to provide timely access for at least 400 new patients per year to yield the desired surgical volume.

    The duration of visit types is often a contested issue, but providers must understand that the duration is intended to be the average amount of time the provider needs to be present for the visit. Practices often make the mistake of including any pre- or post-work required for the patient’s appointment (e.g., history and physical, checkout process), but this reserves too much of the provider’s time and lowers capacity. Visit durations are often designed as a “worst-case scenario,” with providers and managers trying to account for the longest possible patient visit, not the average time spent.

    Enhancing capacity to improve access

    Improving patient access is a financial, strategic and operational imperative. When considering access as a balance between supply and demand, medical groups can focus on what is most in their control: the supply, or provider capacity. Because providers are a medical group’s most valuable asset, a thorough analysis of their time, productivity and efficiency should be conducted routinely. By assessing capacity, managers are able to determine whether current provider time is being maximized. Only when it is optimized should additional providers be hired as a means of further expansion. Now more than ever, practices must focus on their financial sustainability, and thoughtful management of patient access is a critical piece of this puzzle.

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