Extreme Makeover

“I don’t do that, do I?” asked the physician of her office manager. The office manager responded, “Yes, but your intentions are good.” The question and answer, replicated around the room at a town hall meeting about the California Medical Association’s “Extreme Makeover” project, followed observations about the unintended events and role ambiguity that complicate operations in the physician office environment.

The “Extreme Makeover of the Solo and Small Group Practice” is a project funded by the Physicians’ Foundations for Health Systems Excellence and being directed by Nileen Verbeten for CMA and the CMA Foundation. The project was conceived following a study of the issues faced by solo and small practices conducted by CMA in 2002. Interviews with physicians in that study found common themes as solo practices struggle to survive. Among the key challenges: difficulties in claims submission processes; payer inconsistencies, delays and denials; daunting administrative demands; inefficient work processes; excessive rework; staff turnover, training, and retraining; and an absence of technical resources and information infrastructure to keep up with changes or connect with external resources. The goal of the “Extreme Makeover” project is to understand how reducing administrative burdens in the practice can contribute to an improved experience for the patient, staff, and physician, and contribute to improved practice viability.

The initial phases of the “Extreme Makeover” project convened volunteer primary care practices in the Alameda Contra Costa County Medical Association in which the lead physician and office manager of each practice worked with organizational designers and subject matter experts to investigate the barriers to smoothly running, financially sustainable practices whose operations are patient centric, i.e., focused on service quality from the patient’s perspective.

The physician volunteers constructed a mission statement to describe their mode of practice: “The purpose of the solo/small group practice is to provide personalized, high-quality care that is efficient, timely, compassionate, and state-of-the-art.” They then established goals and metrics that identified the desired state for their practice. Embracing this mission statement and physician-established goals, the office managers dissected the administrative functions of their practices. To set the parameters for their work, the managers began with the desired outcomes of the work as determined by the physicians and identified where the work breaks down. These office managers formed a dynamic team, tackling their task with enthusiasm. From five independent practices of family practice, internal medicine, OB/GYN, and pediatrics specialties, they brought real clarity to the day-to-day routines and performance hurdles that were surprisingly common among them, despite their difference in patient populations, payor mix, and services provided.

Intake is challenged by a withering volume of calls that complicate responsiveness, completeness, and accuracy. Patients sometimes arrive late. Insurance information is frequently incomplete. These clog the works, cause delays for other patients, and sometimes result in patients being identified as ineligible for payment either prior to rooming or in the billing process where corrective action is unpleasant and time-consuming.

Breakdowns or slowdowns frequently occur at discharge in executing orders, patients’ lack of understanding about the physician’s recommendations, and challenges in collecting patient amounts due at time of service.

Getting paid is complicated by an overly complex payor environment whose myriad of rules and processes make life difficult. The cost to manually audit payment accuracy exceeds resources reasonably available.

All of this is further complicated by processes that may not be thoroughly understood and consistently implemented, given the pressures of the day, staff turnover, and process documentation that may be insufficiently developed, missing, or outdated. The lack of meaningful metrics against which to measure performance hampers identifying where attention may produce value.

What can be done? Many of the repetitive tasks required in the practice can only be effectively and efficiently handled through the use of technology designed to eliminate these tasks. Two forms of technology interventions that the “Extreme Makeover” project will test deal with revenue cycle management and patient communications. Beyond technology interventions, streamlined processes to address role ambiguity and inadequately defined workflow could prove valuable. Processes and tools to receive attention include:

1. Diagnostic tool for physicians (readiness tool)
2. Documented design recommendations end to end:
   1. Work design
      1. Call volume assessment tool
      2. Standardized administrative processes to ensure practice goals
      3. Revenue cycle management
   2. Structure
      1. Role clarity tool (revenue cycle management, people management)
3. Information
   1. New patient orientation package
   2. Streamlined intake/reminder forms
   3. Patient checklist for visit
   4. Practice measures
4. People
   1. Behavioral interviewing with an interviewing schematic
   2. Performance management
   3. Progressive discipline
   4. Termination
5. Rewards
   1. Work sheet to create practice reinforcement
6. Monitoring
   1. Dashboard work sheet

The project entered into a pilot phase in February. Having invested weeks of effort in identifying where work breaks down, the office managers — supplemented by subject matter experts and our organizational design consultants — will design streamlined workflows and tools scaled to the solo and small practice. Together, they will implement their agreed-upon processes and refine them where they do not work — where they do not improve the ability to meet specified outcomes focused on maximizing the patient’s positive experience while minimizing the practice’s administrative work. An instructional designer will work with them to translate their work into templates usable by other small practices. Some practices will implement only these streamlined designs. Some will implement one or both of the technology solutions. All will engage in data collection and monitoring of results to study the outcomes.

Has the project focused on the right problems? To test whether the problems identified by these office managers resonated with other small practices, focus groups of office managers were held in San Diego, Sacramento, and Visalia. The mission statement and desired outcomes of the steering committee (physician participants) and findings and recommendations of the design team (office managers) were presented to these focus groups. In every session, the office managers confirmed the findings and applauded the proposed solutions as addressing issues of importance to them.

But what about physician reaction to these findings? Two town hall meetings held thus far find mixed reactions: interested engagement; frustration that we focused on these “irrelevant” issues when efforts would be better spent going after the health plans; denial that these issues were significant, appeared in their practices, or would make a difference (despite their office managers’ meeting attendance and validation of the issues). Recognition that the “battle” must be fought on multiple fronts is critical to effectively confronting the issues challenging the solo/small group: CMA can play a valued role in continuing to represent physicians at both a legal and regulatory level, support such as this project can be provided by CMA and the Physicians’ Foundations, direct engagement with physician practices through CMA’s Center for Economic Services, and the advocacy activities of SDCMS all are important, but the physician must recognize their role in addressing what can and must be managed by them. Engaging physicians in the improvement effort is critical to success — not only of this project but for their practice. As the project moves forward and the data collection effort produces results, we hope to have data to inform decisions about the value of the tools being developed.