Balancing the supply and demand of patient access

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.

The importance of timely clinic appointments continues to be a priority for healthcare leaders, many of whom are also increasingly focused on patient access to drive growth and enhance their financial bottom line. Despite its importance, understanding and reporting on access has remained inconsistent, and many leaders are not sure where to begin.

Organizations tend to use proxy metrics for capturing access performance, such as the average number of days from when an appointment was scheduled to the date of service, or the percentage of new patients seen within 14 days; however, perhaps there is a more precise and proactive way to capture this data: a framework in which access is articulated as supply and demand. Using this framework offers a way to address the imbalance in supply and demand based first on, and in response to, an assessment of the practice’s current state.

Supply

As a first step to enhancing access, a practice must analyze its supply of available appointments. Most clinical practices value new patients as an indicator of health and vitality; therefore, we will articulate supply as the number of available new patient appointments — filled or unfilled — either for a practice or specific provider.

To measure supply, managers can quantify the number of dedicated new patient blocks or any time made available for new patients within a given time frame. Some EHRs will report on this metric automatically or, if not, a proactive template analysis can be performed. As Figure 1 illustrates, supply should be compared to demand on a periodic basis, either weekly or monthly, and ideally at the individual provider and practice level.

Demand

Since supply is the number of available appointments, demand is simply the quantity of patients seeking a new patient appointment from the practice or provider. While the concept is easily stated, tactics for measuring demand can prove challenging. Capturing current demand for appointments requires assessing all of the practice’s “front doors” or methods for requesting an appointment, including:

• Incoming calls
• Online requests 
• Visits scheduled online
• Referrals or orders sent to the practice
• Walk-in appointments.

Although this list may not capture every patient who considered the practice for a new patient appointment, it will provide insight as to how many slots would need to be available to accommodate most requests.

Unique demand versus total demand

Delineation of total demand versus unique demand is an important element of a practice’s demand assessment. The concept is that one unique patient may occupy more than one appointment slot when factoring in rescheduling and cancellations. Therefore, if a practice has 50 unique patients per day requesting appointments, the practice must supply more than 50 appointments to accommodate the demand.

A pattern assessment of total versus unique demand allows the practice to understand the rate by which supply should be increased to account for patient cancellations and reschedules. For example, if a practice’s combined cancellation rate and no-show rate is 20%, templates should include about 20% extra slots to account for unfulfilled demand. The rate by which total demand exceeds unique demand will vary by practice and be dependent upon factors such as the patient population and scheduling preferences.

Taking action

Once the supply and demand assessment is done and a practice has at least a few months’ worth of data to analyze, action can be taken to find balance between supply and demand. As Figure 2 illustrates, the practice can be categorized into one of three scenarios:

1. High demand and low supply
2. High supply and low demand
3. In balance.

Scenarios 1 and 2 are actionable; outlined below is an overview of how managers should respond to achieve balance.

High demand, low supply

When demand exceeds supply, an organization will experience long wait times, as appointments are pushed out. In this scenario, the practice is delaying visits, and consumers may seek care elsewhere, particularly consumers with greater options and flexible insurance plans. When long wait times persist, practices experience fewer new patients relative to established patients, which may also result in fewer procedural or surgical encounters, diminishing a key pipeline for growth. Moreover, wait times will negatively affect the patient experience and lead to increased risk of losing patients to competitors.

Tactics for improving supply

1. Rightsizing provider clinical hours often proves valuable in increasing capacity. A provider’s clinical effort (cFTE) should be compared to the actual hours spent providing patient-facing, billable care. For example, if a provider is 1.0 cFTE, and the organization has set an expectation that this translates to 32 patient-facing hours per week, a best practice is to periodically evaluate whether alignment exists, or if there is opportunity to increase provider clinical capacity. If an organization finds that it is not receiving the number of expected hours, intervention may be needed to understand how this can be achieved to gain capacity and new patient supply.
2. If existing provider clinical time is already optimized through overall clinical hours and template management, a practice should consider hiring additional physicians or advanced practice providers (APPs). With the goal of increasing available clinic supply, hiring a provider who will offer immediate availability is an important strategy, as opposed to hiring a local, in-demand physician who will merely transport his or her wait times and backlog from one organization to the next. The process of template design and management outlined above should also be utilized with newly recruited providers.
3. Once provider clinical time has been rightsized, design of scheduling templates is the next priority. Practices should ensure sufficient new patient blocks exist within templates and that the number of dedicated blocks is aligned with benchmarks or industry averages. For example, within the cardiology practice, a general cardiologist tends to see fewer new patients (approximately 1 new for every 6 established patients) than a proceduralist such as an interventional cardiologist (a ratio closer to 1 new for every 3.5 established patients). Surgeons and proceduralists require even better access for new patients but will ideally refer these patients back to a longitudinal provider, such as a primary care provider (PCP) or general cardiologist in this example, following the surgery or procedure. Other factors that influence how many new patient blocks are in each provider’s template include maturity of the clinical practice, and whether the goal is to grow or simply maintain the practice. Beyond rightsizing the number of protected new patient blocks, a practice should periodically review templates and scheduling protocols to address barriers to access such as personal or charting blocks, and whether visit durations can be shortened to accommodate more patients.
4. When trying to increase access, many practices are faced with the issue of too many established patients already populating schedules. Partnering with physicians to transition patients either to an APP or back to their referring provider for co-management is a proven method to counteract this. In the case of a cardiologist, for example, the patient is likely seeing a PCP at least a couple times per year and between the PCP and cardiologist, the patient’s cardiac care can be managed, particularly for lower-acuity clinical conditions routinely managed by either provider independently. Alternating visits between these providers creates opportunity for additional new patient capacity.
5. Practice and provider no-show levels should be monitored on a regular basis to minimize their negative impact on access. Standard tactics for reducing no-show rates can be utilized, such as increasing reminder call frequency, and manually calling patients who have a higher likelihood of no-showing; however, once the no-show rate is relatively low and stable, it is unlikely to be further reduced and the practice should consider thoughtfully concurrently booking appointments (e.g., overbooking). A conservative approach when starting out is to add one additional patient per half-day of clinic, doing so toward the middle of the clinic session. For example, if a provider sees patients from 8 a.m. until 12 p.m., adding the concurrently booked appointment around 10 a.m. will minimize the negative impact on the provider and other scheduled patients.

High supply, low demand 

Despite the emphasis that many organizations place on improving patient access, it is possible to have too much access. With excess capacity, providers will have unfilled schedules and will be waiting for patients — a scenario that will yield high-performing access metrics, but the cost to a surplus of access is high and if sustained, typically more harmful to business. When faced with low demand for services and an excess of available appointments, organizations must work to increase demand, or risk provider inefficiencies and programmatic stagnation.

Tactics for improving demand

1. Consumer-direct marketing and advertising is another method for increasing demand for appointments. In a competitive environment, this often involves promotion of the organization’s specific competitive advantages, including unique providers, services and therapies.
2. Marketing and outreach to other providers can encourage timely referrals to specialists. This is often effective when promoting new clinical programs or therapies and may be best delivered as an educational session.
3. Utilize staff to proactively call patients who have orders or referrals placed but the appointment is not yet scheduled. Patients may have forgotten to schedule or may be considering scheduling with another program. A friendly phone call from a scheduler may help capture some of these appointments, and most EHRs will track and generate lists of referrals placed but not yet scheduled.

Ultimately, the goal of a practice’s access initiative should be to find equipoise between supply and demand, which in turn will maximize patient access and foster programmatic growth. While access is dynamic and will change over time, most common metrics rely solely upon retrospective data, which can force managers to play catch-up, often weeks or months behind when access issues arise. Furthermore, common access metrics leave room for unintended consequences such as over-supplying capacity without regard for longer-term business implications.

This supply and demand framework provides managers the tools necessary to accurately assess their current state, both retrospective and prospective, and to then respond thoughtfully with actions that better align their business and serve patients.