Consider alternatives to adding provider

Q: Our two-physician family practice is operating close to capacity. We’re expecting many new patients when the Affordable Care Act is fully implemented and are wondering whether we should stop accepting new patients or add a provider. Thoughts?

A: I would advise you to think carefully about either approach. You may be increasing your capacity with another, costly physician when it may be that all you need is to gain control over your appointment book. And because all revenue in a primary care practice depends on a steady supply of new patients, it can be deadly for word to get out that your practice is great but is not accepting new patients.

To increase your practice’s revenues, you must be open to new patients with new problems. 

The best way to get control is by rationing those appointments that can wait. Begin by tracking the number of emergent appointments made each day. We define an emergency as any patient who needs to be seen today for whom no appointment was on the schedule when you opened the doors this morning.

Emergencies include people who are sick and injured, of course. But the designation also can apply to anyone you regard as a very important person (VIP) for any reason. Maybe they have the problems you especially like to treat, or they were referred by a VIP source. By saving space on the schedule for patients who really need to be seen, you can effectively screen out patients whose needs are less urgent.

Consider the following example: An orthopedist can see four patients per hour. On Thursdays, he works all day in the office, starting at 9 a.m. He likes to be finished with the last patient by 5 p.m. and be out the door by 6 p.m. Allowing an hour for lunch, that’s a total of 7 hours of patient contact time, which equates to approximately 28 encounters.

We also know that the doctor can expect four emergency (work-in) patients and one no-show in any given Thursday, and that his schedule consists of about 40% rechecks of existing conditions. That means the doctor will need to save three slots on every Thursday’s schedule for same-day appointments. That leaves 13 slots for other routine patients, not in the emergent or follow-up category.

Now comes the difficult part. When the slots for this particular Thursday are all gone, the practice schedulers can’t book any more non-emergent patients on that day. Sure, if legitimate emergencies come up, you’ll have to work longer. Nobody will turn away really serious medical problems or VIPs. But with our plan, it’s the non-emergent, non-VIP patients who are pushed into the future.

To implement this concept, you need the data about how you really see patients. That means your true rate (patients per hour) and the number of no-show and last-minute cancellations you experience. Finally, you need to estimate the number of same-day appointments you will experience. You can start collecting that information by counting these items at the end of each day and noting the totals on the appointment schedule.

Mondays often have more same-day visits than any other day. That’s because of the pent-up demand that  often is created over the weekends. Other days have their own idiosyncrasies, so be sure you separate your statistics for each day of the week. Throw out the Tuesdays after long weekends, too. They will distort your usual experience.

Keep the statistics from now on, and check your experience from time to time to monitor any changes in your practice patterns. You may have seasonal variations, for example.

You will need to supervise this system closely if you expect it to work. The applicable management aphorism is, if you expect, you have to inspect.

To make this system easier to use, pre-designate on your appointment template (color-coding is the best way) the emergent slots (pink, say). Slots with the designated color cannot be filled until that day or until after 4 p.m. the previous day. If you find a pink emergent slot filled in on the schedule for the day after tomorrow, your staff members do not understand the need to keep it open.

It is best to save these “emergent” slots until the end of the session. That way, if you don’t fill them, you can close up shop and get home in time for dinner for a change.  

The answer to our reader’s question was provided by Judy Bee, Practice Performance Group, La Jolla, California, and an editorial consultant to Medical Economics. Send your questions to medec@advanstar.com.Also engage at: www.twitter.com/MedEconomics and

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