Primary Care: Developing An Efficiency Decision Guide (Text Version)

On September 28, 2010, David West made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (350 KB). 

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Primary Care: Developing An Efficiency Decision Guide (work in progress)

AHRQ Annual Conference
(September 28, 2010)

A Report from SNOCAP-USA

Contract Number: HHSA290200710008
(July 2009 through December 2010)
Dr. Michael Harrison: Task Order Officer 

Slide 2

Disclosure Information:

Presenter: David R. West, PhD

University of Colorado
School of Medicine
Colorado Health Outcomes Program (COHO)

I have no financial relationships to disclose
and
I will not discuss off-label use and/or investigational use in my presentation

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Session Objective

• To provide participants with information regarding current gaps in evidence for process improvement in primary care and the insights gained, to date, through research into the major contributors to primary care practice efficiency.

Slide 4

Exploring Ways to Improve Efficiency in Primary Care

SNOCAP-USA Team: AHRQ Task Order

• Kathy James, PhD
• Betsy Vance, MPH
• Steven Ross, MD
• Tiffany Radcliff, PhD
• David R. West, PhD (Task Order Leader)
  • Acknowledgement: Thanks to MGMA

Slide 5

Specific Aims

• Review, Summarize and understand the current literature regarding efficiency in primary care.
• Understand how primary care practices think about and implement efficiency measures, and factors associated with efficiency/inefficiency in these practices (in depth in Colorado, and phone interviews).
• Develop and test an "efficiency" decision-guide for use in primary care practice.

Slide 6

Literature Scan

Defining Inefficiency Waste:

1. Brent James' definition of inefficiency waste as "using more inputs than is necessary to produce a unit of care to benefit patients, and has strong linkages to the design of care systems" (James and Bayley 2006).
2. Litvak's definition of inefficiency waste as variation and lack of standardization of processes in the practice setting, including clinical variation (i.e., variation in the care provided), flow variation (i.e., variation in the demand for healthcare), and professional variation (i.e., variation amongst providers (Litvak, Buerhaus, et al. 2005).

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Factors [Reported to be] Associated with Inefficiency Waste in Primary Care:

• Practice processes, including improved practice work flow, patient flow, and physical configuration.
• Electronic modes of communication amongst practice personnel and with patients.
• Improved coding to increase reimbursement.
• Computerized physician order entry (CPOE).
• The use of the EHR as a tool to address nearly all of the above listed factors.
• Practice size and complexity.

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Tools and Measures for Addressing Inefficiency Waste:

• Moving historically from continuous quality improvement (CQI) and total quality management (TQM), to Six Sigma and Lean; these techniques have applicability (and a track record) for use in measuring inefficiency waste and tracking the improvement of practice/clinic/organization operations in primary care settings.

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Secondary Data from MGMA "Cost Survey"

• Information provided by hundreds of practices that responded to the annual survey from MGMA—slightly under 300 defined as primary care (FM/GIM)—not solo, and not multi-specialty.
• Includes data elements such as:
  • Fiscal year revenue.
  • Costs (fixed and variable—e.g., labor, lease, supplies).
  • Inputs (including types of labor and capital).
  • Outputs (productivity measures—relative value units, visits per year).

Slide 10

Econometric Analyses

Preliminary multiple regression analyses predict efficiency (RVUs and Net Operating cost) outcomes using other practice characteristics as the independent variables.

• Rural location of practices was associated with lower operating costs.
• Average costs per billing provider and total number of physician FTE's were directly related to both higher operating costs and RVU's.
• Non-physician providers, when included in practices, had some association with higher practice RVU's.

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DEA Analysis (input-oriented, variable returns to scale (VRS) )

• DEA model input-oriented, variable returns to scale (VRS)—provides an "efficiency" score to divide "efficient from inefficient practices" using numerous variables. Used to select practices for follow-up study.
• Sample size for the DEA was 283 practices.
• DEA identified 19 of the 117 practices as "efficient."

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Primary Data Collection

• Colorado Practices
• MGMA Practices

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A table presents the following information:

Practices	Patient Population	Ages	Payers	Clinicians	Square Feet	Ownership	EMR
A	Metro	9% infant 21% pediatric 7% adolescent 28% adult 4% geriatric 1% super geriatric	5% Medicare 30% Medicaid 19% FFS 4% Cap/CHP+ 25% self-pay 1% Cap	10	226,000	Not for profit FQHC	No
B	Metro?	10% infant 26% pediatric 7% adolescent 53% adult 3% geriatric 1% super geriatric	4% Medicare 65% Medicaid 6% FFS 25% self-pay 1% Cap	13	60,000	Not for profit Verify FQHC	Yes
C	Non-metro	10% infant 20% pediatric 10% adolescent 35% adult 20% geriatric 5% super geriatric	25% Medicare 2% Medicaid 2% FFS 10% WC 21% self-pay 40% contracted insurance	5	5,000	Physician owned	Yes
D	Metro	2% adult 68% geriatric 30% super geriatric	95% Medicare 2% Medicaid 4% FFS	13	5,100	Physician owned	Yes
E	Metro	60% adult 30% geriatric 10% super geriatric	29% Medicare 11% Medicaid 33% FFS 6% Cap 20% often 1% self pay	6.4 FTE	?	Hospital owned	Yes

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Practice Engagement Questions

• Adoption: 1) when did the topic of redesign initially arise? 2) key people inside and outside the clinic responsible for adoption? 3) technical and administrative challenges (including costs of lost productivity and opportunity costs) faced in adoption?
• Current use: 1) how redesign is currently integrated into clinical practice? 2) frequency of use? 3) variability of use among providers?

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Practice Engagement Questions

• Perceived/Realized benefits of current use: 1) organizational costs and benefits? 2) improvements in the quality of care? 3) improvements in the safety of care? 4) improvements in the efficiency of care? 5)changes in culture?
• Future of redesign: What additional functions/data sources could provide additional practice value in the future?

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Findings

• Understanding of Processes that Surround the Patient Visit:
  • Pre-Visit Processes
  • During Visit Processes
  • Post-Visit Processes
• A Desire for Self-Assessment and Improvement
• There are Barriers to Achieving Efficiencies in Primary Care Practices.

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Circular Diagram

Image: An arrow curves around to form a full circle. Boxes with the following captions are placed along the circle:

• Appointments and Scheduling
• Patient Phone Calls
• Verifying Insurance
• Practice Layout
• Hierarchy and Appropriate Staffing
• Communication
• Medication Refills
• Third Party Payers
• Managing Test Results

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Pre Visit Processes

Appointments/Scheduling:

• Problems:
  • Maximizing capacity.
  • Dealing with patient "no shows."
• Solutions:
  • Mixture of Open access and traditional scheduling processes.
  • Remedial Actions/patient consequences.

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Pre Visit Processes

Telephone:

• Patient phone calls are common struggle:
  • Volume of phone calls some clinics receive can cause an inability of staff that handles phone calls (generally the front desk).
  • Patients may not be able to get through and/or experience long hold times.
• Solutions include:
  • Call Centers.
  • Electronic call systems.

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Pre Visit Processes

Insurance Eligibility Verification:

• A critically important but time consuming process with various processes for:
  • Medicaid and CHP+.
  • Medicare.
  • Private insurance.
• Solutions include electronic and automated verification systems.

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Visit Processes

Patient flow during a visit:

• • Observed Problems with layout:
    • Opportunities for bottlenecks—particularly check in and check out.
    • Lack of standardization of exam room layout and patient flow to and from exam room.
  • Solutions:
    • Standardization of exam room layout and inventory control.
    • Use of "PODS" for streamlining flow and removing bottlenecks (in larger sites).

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Visit Processes

Hierarchy/Staffing/Team Concept:

• • Problems with:
    • Defining roles/standardizing roles and responsibilities, maximizing staff capabilities, and off-loading tasks from clinicians.
    • Physician "buy-in" to delegation of tasks.
    • Communication.

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Visit Processes

Solutions:

• • Primary Health Care Team models.
  • Communication tools and huddles to inform team/work together more effectively.
  • Improve Patient Experience and Practice Productivity with Group Visits:
    • Concerns about patient buy in.
    • Lack of information/uncertainty about insurance reimbursement.

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Post Visit/In Between Visits

• Medication Refills.
• Coding and Billing.
• Diagnostic Test:
  • Ordering.
  • Tracking.
  • Incorporation into care plans.
  • Communicating to patient.

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Some Important Lessons

• The competing demands for time and resources within practices must be taken into account when developing a strategy to improve efficiency.
• Both practice leaders and staff must learn to collaborate and co-evolve together to assure an understanding of the models/processes of care to be implemented, and to assure buy-in to the model.

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The comprehensive change of process in practice can be daunting and expensive. However, meaningful change can occur by identifying everyday problems and by implementing common sense solutions. Solutions implemented can evolve over time, as needed.

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Next Steps

• Draft the Decision Guide.
• Pilot Test the Decision Guide.
• Final Deliverable to AHRQ.