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“What satisfies my patients?” Thoughts from 16 providers across 9 specialties in 7 States.

It is a simple and yet very powerful sentiment.

With more and more of physician compensation revolving around patient satisfaction, the healthcare industry is left with what looks like an elusive goal – “What satisfies my patients?”. I was all the more curious about this question myself. I spent the better part of the last 5 weeks calling customers, non-customers and anyone else who was grappling with this question. Can patients ever be satisfied? Is it a perpetual train of more and more favors and an occasional thanks with bad online ratings the moment the waiting room does not smell of vanilla? May be send more portal messages and hope that counts for us keeping in touch? Another email campaign?

As I criss-crossed the country with physician practice interviews, what struck me was the amount of overhead employed to chase the elusive goal of a “satisfied” patient who will take a survey (well, one who is truly satisfied that they will share their opinion with others).

As I and several of our clients started unraveling the onion one layer at a time, we stumbled upon something quite obvious. A patient today has a dizzying array of information coming at them. Many of them may start at Google® before their PCP. Yet, the physician’s front office phone is one of the busiest pieces of equipment in the healthcare industry. It is not uncommon to have ½ FTE as medical assistants/front office staff for each provider in a practice. Why is that? Even with such a heavy-handed approach to providing patient care, physician practices get flak on online message boards for being less responsive. How can that be?

The FTE overload and even with that, online message board flak was prevalent across many specialties. Those interviewed for this article include primary care, orthopedics, GI, oncology, cardiology, pulmonary medicine and more. States in the country where the providers were based varied as well – IL, FL, WA, OH, LA, TX, NY and more. Throwing money at the problem seems to not solve patient satisfaction. The system seems like it needs new ideas.

As I started to spend more time on what keeps the medical assistants busy, it dawned on me. I kept notes at three practices on the number of calls medical assistants took and what the matter was during the call. I then tried to piece together when the patient called and when the callback was done. It was the day after Thanksgiving and I had to call a physician practice myself to make an appointment for a family member. I tried the portal and then the phone…and waited for a few days to get the matter resolved. A few patterns started to emerge as I put my own experience together with that of the interviewees.

Before I share what I learned, let me ask you…do you think you are a “satisfied” patient? What causes you dissatisfaction? To discuss further, conctact Badri at badri@alertmd.com.

What is your overhead?

AlertMD® has given me a unique 10-year window into a day in the life of a clinician and all the administrative overhead that they have to undergo before they get paid for their hard work. Being an engineer, I could not but help applying the principles of industrial engineering to the process. What is the overhead and what is the processing time? Those were fundamental questions for me.

On numerous occasions, I had to do a walk through and got to see the amount of time a clinician spent with the patient (value-added time) and everything else (overhead). Here is what I found:

  • Patient contact - 25%
  • Family discussions - 10%
  • Hospital support staff, orders - 10%
  • Documentation in the hospital - 25%
  • Documentation back for the practice - 10%
  • Handoffs, communication within their own group and other groups - 20%

To be clear, all 100% is necessary for the system to function. However, the sheer amount of overhead for the 25% of patient contact seemed stunning to me. I set out asking the question “why?” to each step other than patient contact. If the provider would stop and write down something, I would ask Why. If they then stopped and repeated what they just entered into the chart to another party, I would ask Why. When they would go to the staff lounge and effectively redo the same work they did in a chart, but only slightly differently, I would ask Why.

The lessons were painful. After spending billions on allegedly interconnected systems that are in an information highway, the provider on the front line is saddled with repetition of the same information again and again in multiple software. The provider then has to call and relay that information to a different party all over again. While this is going on, reimbursement drops by a couple of percentage points each year. In other words, the provider has to work 2% harder to make the exact amount as last year.

Dejected from the reality, I assembled a smart team of people and asked a few questions…

What can we do to slash the time spent on overhead by a factor of 7? In other words, handoffs and communication should take 3% of the provider’s time and not 21%, as an example. What can we automate? How can we reduce/eliminate repetition?

Before I discuss more of what we ended up doing, perhaps you can share your thoughts. Do you agree with the premise? How is your $30,000,000 system working? Saving you time? Are you repeating the same thing again and again, only changing it a bit just to get by?

Contact Badri Narasimhan badri@alertmd.com to discuss more...

Why did health systems decide to make their own generics?

Recently, there was an announcement that some major health systems were banding together to make their own generics. At the outset, it looks like the health system wants to be an insurance company and then a pharma company – what is next? Is this their core competency?

When you step back, the strategy behind it is simple and obvious. To better understand it, let us shift focus and look at a completely different industry – the luxury automobile industry. Assume you have owned a luxury car for a few years and the manufacturer’s warranty has expired. Let us say you need your oil replaced or you need a new tire because the right rear tire has its treads worn out. What do you do?

In all likelihood, you expect to drive to a retail store (e.g., one of the fast lube companies) and get the oil change for an inexpensive sticker shock. For the tire replacement, perhaps you expect to run into a wholesaler who happens to sell tires or a specialty retailer of tires and buy a tire and replace the one with the worn-out tires. You behave this way because you own the incremental expense. It comes out of your pocket. You want to control the costs.

A health system is in a similar spot. In today’s world of risk-based health, the system gets paid a fixed amount for the patient per month or they have an alternative payment model that still caps their revenue. The system needs to identify elements of its costs that it can reasonably control. Keeping patients healthy involves seeing them at the PCP more and intervening before the medical needs of the patient becomes acute and incur higher costs. The system knows how to do that very well. However, one of the drivers of costs is medication. Health systems need to purchase drugs from manufacturers and the cost of medication in a risk-based scenario are borne by the health system. Any method to control that costs or reduce them puts the savings directly to the bottom line.

The traditional methods of cost control of medications have involved the health systems banding together to form purchasing groups. Some have staff that actively monitor prices. Others use physician committees to identify lower priced drugs that can substitute the higher ones and provide efficient care. It was only a matter of time before a health system decided that they may want to get into the business of making such drugs. However, patent laws prevent a health system from manufacturing brand name medication. Such is not the case with generic drugs. Generic drug manufacturers sell them at a profit to health systems today and the announcement earlier today is an indication that health systems are trying to reduce the total cost of care by manufacturing generics.

Where will the industry go from here? I happen to think that cost control in pharmaceuticals is just the beginning. Let us pick up at the luxury automobile scenario to see where we are in that industry. When you pulled up at your lube company or tire store, what happened? Were you able to get an oil change or your tire replaced?

In all likelihood, you got a shocking reply. The oil change can be done, but there is a special computer signal that will not turn off and thus, your car will continue to think that the oil is old. The filter has a special component that is not sold to the 3rd party service shop. You have to go to the dealer for it. In the tire scenario, even if the tires are a national brand, the treads are custom to the luxury car maker and you cannot purchase them in the market. You have to get the replacement time at the car dealer. What does it all mean? The luxury car manufacturer has found a way to keep you captive in some ways.

Why does this matter? I believe that in healthcare, the large health systems that have research prowess will start making custom implants or splints that can only be purchased at their facilities. Perhaps a brace that can only be put on and taken off at one of their provider facilities. What if there was even a medical device where the patent enables the health system to only offer it at their facilities? These are ways for the health system to differentiate themselves and keep their costs low, while also creating a strong relationship that is somewhat captive to them. A less-intensive version of this is already in play today. There are certain surgery techniques that are practiced in some nationally renown facilities and are captive to them.

As health systems grapple with being a risk-bearing entity, look for more ways in which they will try to build competitive advantage in the top line (unique procedures, unique splints, etc) and ways to build competitive advantage in the bottom line (make generic drugs, make simple medical devices themselves, etc.). The future is looking like a branded experience for patients.

Contact Badri Narasimhan badri@alertmd.com to discuss more...

Industry Recognition for AlertMD

Healthcare Financial Management Association (HFMA)’s IL Chapter publishes article recognizing AlertMD's own Badri Narasimhan.

The article discusses the future of healthcare and technology with also stating Badri as an "innovator shaping the future of healthcare." The interview with Badri covers a wide range of topics including where mobile technology is headed in healthcare and how it can help hospitals. The full publication can be found here. An excerpt of the interview is shown below:


Innovator Shaping the Future of healthcare

Interview with Badri Narasimhan, President & CEO, AlertMD, LLC
By: Dan Yunker, VP & CFO, Metropolitan Chicago Healthcare Council

DAN: All of us have experienced mobile technology change in our daily lives - everything from buying movie tickets to depositing checks in a bank by taking a picture. How has it impacted the physician?

BADRI: The impact on the routine tasks of a physician is yet to come. Most of the applications that are available for a physician today are reference applications. Instead of carrying a book or a "cheat sheet," a physician may access apps to evaluate the scores for various risk assessments or look up codes for billing. Some use mobile apps to access their office network and then turn around and launch a full-fledged desktop software via a mobile device or tablet. All of these are in the infancy of mobile apps to come.

There are products with the ability to take a picture of the barcode on the bracelet of a patient and from that gather the necessary demographics of the patient (through an interface with the hospital) and digitally send the facesheet to the practice, register the patient and enter professional fees in seconds. Whereas this sounds futuristic, when done well, it is the simplicity of the process that drives adoption. Instead of taking a picture of the check to deposit, the physician takes a picture of the barcode and enters charges -- it can literally be that simple.

DAN: Why would a hospital want to provide an interface to enable this kind of billing?

BADRI: The are several reasons. For one, an easy billing process for physicians makes it incredibly easy to do business at the hospital. If I as a physician practice at a few different hospitals, I am going to gravitate my patients towards the one where it is the easiest to do business. Technology is certainly not the make or break factor in such a decision, but a lot of little things add up to a decision and such technology becomes yet another factor in making a good hospital great.

DAN: We have seen many hospitals focus on their physician relationships. How inclined are hospitals to implement technology to increase ease of doing business?

BADRI: Great question. Products that only improve the lives of physicians are likely to meet with resistance. If a product can both cater to the physician group and be beneficial to the hospital, there is a good opportunity to provide value to all. For example, a highly efficient process for the hospital to make the ICD9/ICD10 diagnosis codes in the employed and independent physician's professional fee process consistent with the hospital's DRG-based billing process may be delivered by a technology that also makes it easy to do business at the hospital. This is a win-win. Today, the hospital employes several documentation specialist nurses who either round with the physician or round separately to identify opportunities for improving documentation, identify DRG changes, review it with the physician and complete the review. This process is ripe for innovation. As we move from fee for service to fee for value, documentation becomes king and any inconsistency between physician offices and hospitals become the enemy.

DAN: Now that you mentioned ICD10, what, if any, are ramifications of ICD10 on software at the hands of physicians today?

BADRI: The changes are dependent on how the software vendor chooses to tackle ICD10. The physician should be spared the effort of training in billing. Physicians should search for the codes in plain English (e.g., hip pain) and the complexities of which code it maps to behind the scenes are dealt with by our product. For example, pain in the left and right hip are one and the same in ICD9 but the physician should not need to know or care about it. The same should hold in ICD10. Where there are additional questions or clarifications, technology should walk the physician through them in English and keep the complexity away from them.

DAN: When will mobile technology start impacting other staff members around the hospital such as nurses, pharmacists, etc.?

BADRI: Pioneering work is being done by many players there as well. Nursing labor is one of the top three expense items for a hospital P & L and yet the budgeting for that follows a crude algorithm of counting the number of patients in the bed at midnight on a day. The activity during the day when there were 50 admissions and 50 discharges compared to one where there were five and five are not even comparable... but based on today's industry metrics, the expectation would be that the costs for both days are the same! This metric (nursing labor per patient day) is ripe for innovation as well.

Some day in the future, each nurse may carry an app that will be like a weather forecast. Instead of showing how likely it is to rain in the next four days, it will show how likely it is that this particular nurse with be called in over the next few shifts.

DAN: Any closing comments?

BADRI: We are in the new age of shared hospital and physician interests. What is good for the hospital is now good for the physician and vice versa. There are several technology solutions that cate to extracting maximum value from this reality. Hospital administrators should seek to find the best solution for this needs. The time is now for leaders. The followers may lose market share and may be forced to adapt trends instead of gaining competitivity advantage by moving early.

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