Chronic Care

In 2010 the chronic care disease state was responsible for 7 of every 10 deaths in the US and over 75% of the total health care costs. What is the percentage of patient visits – new and established that have a chronic care diagnosis? How do you treat them?

Today, the provider is so busy completing PQRS/VBPM and Meaningful Use requirements that it is estimated that only 55% of the providers day is actually involved in directly providing patient care. In addition, the overall care that is provided addresses the immediate need and may not address the on-going needs for managing the chronic care needs of the patient.

What can you do improve chronic care to patients in your office?

• Develop treatment plans and protocols around those key disease states. 
• Consider multiple chronic care states, e.g. 20% of Medicare patients have five or more chronic diseases and 10,000 US citizens become eligible for Medicare on a daily basis 
• Seek others to join the team or care process such as dietitians, certified diabetic educators, exercise physiologists, behavioral health professionals. These may be contracted or employees. There are key codes today in transition management of post hospital patients and chronic care codes for services covering 30-days. Now is a good time to look at the volume, team and see if there is anything that can be done to expand services. 
• The team can also be used during “shared medical visits”, SMV. An SMV brings around 15 patients together for a group visit. There is education, answering questions (the same one once rather than 15 times), and time set aside for individual visits, e.g., extract a patient for a few minutes from the group for an individual visit. Use established visit E & M codes 
• Consider the local market and assume some responsibility for population health management, broaden the perspective of patients needs, know the resources available in the community, and communicate healthier measures to the patient 
• Work closely as referred and referee of patients to insure the patient is receiving well coordinated care. 

The coming changes in reimbursement, less emphasis on fee for service and more on risk sharing, performance based approaches lead me to believe that managing these patients well will be a positive benefit maybe not today but certainly tomorrow. Now is the time to think about it.

Medical Practice Staff and Patients

There was a book published several years ago by Jan Carlson of Scandinavia Airlines entitled “Moment of Truth”. Basically his point is that every time a customer comes in contact with a business a moment of truth is formed. These moments of truth create an impression which leads to thoughts about whether or not they should continue to seek products or services. Negative impressions will lead to the customer seeking other alternatives.

If we realistically look at the patient visit to the medical practice most “moments of truth” have to do with staff and the environment and NOT the provider. This is not to say that the provider portion of the visit is not important, it is the reason to be there, but it is to say that the staff needs to always be at their best.

So think about a few scenarios and how you respond:

• Patient yells – do you yell back or allow the patient to “vent”, listen and once the complaint is out, respond in a cool manner. Utilize the reflective/deflective listening approach which means you repeat what the patient said and attempt to reach common ground and a resolution of the issue. 
• Patient cries – they have just gotten bad news, time to empathize and recognize their need. 
• Use common language – it is noted that patients don’t understand medical terminology, make sure your discussion is in common language. 
• Pay attention – listen to what they have to say 
• Patient is late – offer them alternatives such as rescheduling or waiting to be worked in. We have done a good job of training patients, they expect us to be late so they can be late as well 
• We are so busy – instead of stating to obvious about a stressful day, don’t and try to calm down, relax and treat the patient with care and respect. Don’t let them know you’re too busy to see them – they’ll become stressed! 
• Treat them like you want to be treated – the golden rule 

Then make sure the reception area is clean, maintained at a comfortable temperature, includes entertainment such as wi-fi, TV, recent and relevant periodicals.

Patient satisfaction is one of the key metrics in Medicare and payer programs and plans, it is essential that we all do our part.

Medical Practice Question: To Charge, or Not to Charge for No-shows

A question that I am often asked is whether or not there should be charge for no-shows. In most cases this creates bad vibes with patients and creates a lot of work on the back end with little results. A blanket response to a provider complaining at a board meeting about the fact that there are a lot of no-shows is not appropriate.

What is your percentage of no-shows per week? I am not aware of a good benchmark but in talking with practices, the goal of less than 3% seems reasonable.

Instead the root cause of no-shows should be considered. Here are a few questions that should be asked when the issue of no shows comes up:

• Is it one provider? 
• Is it one day of the week or time of that day? 
• Is it one payer type? 
• Is it one age group? 
• Is it new patients? 
• How long from the call to the appointment? 
• Is it established patients? 
• Repeat offenders that can and should be dealt with individually? 
• Others in your practice? 

The main point of this is that the administrator should have sufficient data in place to offer a well thought out plan. A blanket response implies unawareness, laziness, or reactionary decision making. This type of action often times causes more problems than offers solutions.

This does not mean that a no-show charge is not warranted, it may well be for certain patients, e.g., a behavioral health patient that has difficulty with responsibility may learn something from having to pay for that a mistake.

We may have done such a good job training our patients that we always run late that they can come in late or maybe not bother to show up since they are feeling better.

We may have a provider that needs help with bed side manner and efficiency.

We may have a scheduling issue and schema and protocols needs to be changed as a result of the analysis of data.

I am sure you can find many more reasons, come up with solid solutions and develop a well thought out transition plan to address those solutions!