Max, Uber, and Patient Access
As a frequent business traveler, I’ve become a customer service snob. A few years back, I relocated to a neighborhood to be closer to the airport so that I could take a cab to and from the airport. This saved me time (no 45-minute drive each way to the airport and curbside drop-off), aggravation (landing on a Friday night three terminals away from my car), and money (round trip cab ride of $70 versus $125 for a week of terminal parking).
Most of my trips to the airport were with Max, a great fellow who was an independent driver for a national franchise cab company. To use Max, I had to plan ahead by calling 24 to 48 hours in advance to confirm his availability. Max was always on time, his cab clean, and in good repair (little things matter, like working seatbelts). My trips from the airport were less than stellar because of the antiquated rules associated with how cabs operated at the airport. Efficient, yes. I seldom had to wait, but the cabs were often old, smelled, and came with drivers that often had an attitude because my fare was going to be lower than they expected after waiting in the airport cab queue for more than an hour. If I could have Max on both trips, then life would have been good, even at $35 each way, because of the service. But I can’t – rules are rules. So I’ve fired Max (and his colleagues at the airport) and hired Uber.
Uber does for me what others can’t or won’t – an on-demand smart phone app showing who my driver is, what kind of car they are driving, where the vehicle is in relation to my terminal location, and what my cost is going to be for the trip before I step into the ride. No 24 to 48-hour pre-planning. Instead, I get customer-focused drivers (I get to rate them online within minutes of my trip being completed); a clean, late model vehicle with working seatbelts; and I save over 50 percent on the fare. Life is good. Sorry Max (and colleagues), business is business.
Tying it Together
What does this taxi story have to do with patient access? Everything. In many urban markets, the taxi industry enjoyed a near-monopoly in and out of airports and had a captive audience. It was a regulated industry with little incentive to change. Then came disruptive competition. Thank you Uber (and Lyft).
Given all of the mergers and acquisitions in healthcare over the last few years, many organizations now enjoy a dominant market share in their respective regions. Not a monopoly, but in some cases an oligopoly. Sure, many of these organizations have outstanding patient satisfaction numbers, glowing patient testimonials, and provide a significant community benefit. But they may also lack the incentive to change like my local taxi industry. As John Kotter said in his book Leading Change, “We need to become less like an elephant and more like a customer-friendly Tyrannosaurus Rex.” As a consulting firm, we are seeing a number of organizations that are not prepared for the disruptive forces of change, like Uber, we are going to see in many healthcare markets over the next three to five years – and patient access continues to be a resonating theme.
In August 2015, the Institutes of Medicine published a far-reaching study on patient access at the request of the VA and the imperative created by the system-wide patient access crisis that was well-chronicled in the press. A panel of industry thought and operational leaders formed the IOM’s Committee on Optimizing Scheduling in Health Care and fast-tracked the most comprehensive, peer reviewed analysis of patient access trends published to date.
All of the committee’s 10 findings resonate and are worthy of a lengthy discussion, but several stand-out in my mind. First is Leadership. The study states, “Leadership at every level of the healthcare delivery system is essential to steward and sustain cultural and operational changes needed to reduce wait times.” As healthcare leaders look at their strategic plans, they must understand that the forecasted cost curve for healthcare is 4.9 percent per year through 2024; patient out-of-pocket spending, mostly for annual policy deductibles and co-insurance, have risen 67 percent since 2010; and that one in five Americans who have health insurance are finding their cost-sharing obligations unaffordable. As costs go up, the financial burden is being shifted to patients. These market factors will force patients to act more and more like consumers as they choose healthcare providers and services. And consumers have service expectations that include timely and efficient access to their providers. If access to care is poor, an environment for disruptive competition exists. In a number of markets, retail clinics and free-standing emergency rooms are flourishing, often at the expense of health system-operated physician practices.
The second point is Consequences. This discusses how delays in access impact outcomes (not good in the population health environment we are heading into), patient satisfaction (see the definition of consumerism), and utilization (also not good in the population health environment). I could argue that consequences should be the first point made, but it will take leadership to drive change around patient access and to transform organizational cultures.
The third point is Contributors. The study highlights a number systemic and cultural issues that impact patient access including mismatched supply and demand, provider-focused scheduling templates, priority-based scheduling queues, and care complexity. In many cases, strong, vision-setting leadership can deal with these issues. Coupled with a systems engineering strategy, quick “wins” can be found. The committee cites a case study with Cincinnati Children’s Hospital and Medical Center Outpatient Clinic that reduced visit appointment types, standardized clinic operations and workflows, and implemented a clinic cancellation policy in an effort to improve new patient access. Although some of these sound like simple, no-nonsense fixes, culture and status quo often prevail.
The final point is Reframing. This refers to alternatives to in-office visits (telehealth), team-based care models, and e-consults. Thanks to more than $12 billion in EHR incentive payments since 2011, we have seen the rapid deployment of technology in physician practices. As the large EHR vendors prepare for population health, they are enhancing their products to incorporate virtual office visits and enhanced patient portals that enable efficient appointment scheduling and the completion of pre-visit questionnaires. In addition, with more and more care now being documented in an EHR, we have longitudinal data to develop evidenced-based care pathways that will support team-based care models, safely deliver a virtual visit, and allow for the adoption of e-consults. An excellent example of leveraging EHR technology investments is the e-consult work that was started in 2011 at the Mayo Clinic (MN), where over 800 providers, mostly primary care, requested consultations across 25 separate specialties and continued to manage the care of their patients without an associated specialty clinic visit.
Our industry is full of bright, innovative leaders with great ideas. We have made significant investments in technology over the last four years and it’s now time for us to become disruptive leaders of change so that our organizations can effectively respond to patient/consumer expectations, evolving reimbursement models, and the need for greater operational efficiencies. The first step is leadership creating the plan for change – before disruptive competition, like Uber, comes into play.
Randy Jones is senior vice president of Culbert Healthcare Solutions.