Case Study: Encouraging Patients to Schedule Annual Physicals

ABSTRACT

The Palm Beach Accountable Care Organization began a preventive care initiative aimed at scheduling visits for patients covered under commercial insurance who had not seen their primary care physicians in more than a year. Reports of “dropped patients” who lost or were about to lose assignment to their doctors were produced and distributed to physician practices. With the assistance of registered nurses and lay patient navigators, physician offices contacted and attempted to schedule the patients on the lists. In just 3 months, this effort retained 1242 patients to their physicians for their annual physicals and potentially saved an estimated $1,892,094.96 for the accountable care organization’s commercial insurance contracts.

The American Journal of Accountable Care. 2018;6(2):26-29The Palm Beach Accountable Care Organization (PBACO), founded in 2012, is the highest-earning accountable care organization in the nation, earning $31.5 million in shared savings alone in 2016. With almost 80,000 Medicare beneficiaries and more than 400 physicians spanning from Miami to Okeechobee, PBACO is rapidly growing its network of providers and patients. PBACO also effectively doubled its patient panel size after negotiating contracts with Cigna and Blue Cross Blue Shield (BCBS) in 2016 and with UnitedHealthcare (UHC) in 2017.

PBACO operates various population health projects to improve care quality and efficiency in south Florida. These include focusing on high-cost/high-risk patients, promoting transition care management for patients being discharged from the hospital, and keeping track of patients frequently admitted to the emergency department (ED). These projects are undertaken by nurses working for PBACO, as well as by lay patient navigators and assignment/provider representatives, who are employees tasked with coordination and data sharing and collecting among physician offices. Evidence shows that lay patient navigators can increase the efficiency of physician practices by reducing 25% of case managers’ nonclinical tasks, while also lowering ED visits and readmissions.¹

PBACO’s most recent initiative involves promoting preventive care for patients who have not seen their primary care physicians (PCPs) for more than 12 months and are thus “dropped” from their PCPs’ panels. According to the results of a study from the National Commission on Prevention Priorities, increasing preventive care utilization could save $3.7 billion in healthcare spending and 2 million lives annually.² A possible obstacle to preventive care is a lack of regular visits by patients to their PCPs. However, the simple offer of free PCP visits has not been shown to increase patient retention. For instance, eligibility for free PCP visits did not increase the likelihood of visits for patients in Mississippi compared with patients in Georgia and Tennessee who were not eligible for a free visit.³ Therefore, additional efforts, like PBACO’s dropped-patient initiative, must be devoted to reaching out to relatively healthy patients who need to see their PCPs annually. With the medical landscape shifting from a fee-for-service model to value-based care,⁴ PBACO must dive deeper into the logistics of population health, especially regarding preventive care. Through the new dropped-patient initiative, PBACO has piloted a simple but innovative endeavor to support consistent patient access to care, maintenance of patient health, and prevention of wasteful procedures that stem from untreated and undiagnosed conditions.

Methodology

First, comprehensive lists of patients who have not been seen in 1 year or more, organized by the PCP and insurer, were compiled based on quarterly reports from Cigna, BCBS, and UHC. From its PBACO nurses, assignment team member, or provider representative, each practice received the lists of dropped patients who had previously been assigned to them. The practice was encouraged to schedule the listed patients for annual physicals. Assignment team members, if permitted, could directly schedule dropped patients on behalf of the practices to which they were assigned. PBACO nurses, although initially not directly involved in scheduling, also began making appointments with the guidance of the assignment team. During scheduling, the dropped-patient reports were filled out to include the dates of the next scheduled physicals or the reasons for the inability to schedule an appointment. Patients who could not be called were sent postcards notifying them that they were due for an appointment. Filled-out reports were returned for data processing to assess the progress of scheduling. The process began in the first week of May 2017 and continued through the second quarter of 2017 (ending June 30), although some reports were returned late by the end of July.

Additional protocols were implemented in mid-June to target patients who had not been reached with an initial phone call. After sending a postcard, schedulers were encouraged to call 2 or 3 more times at different hours, using both the primary and secondary contact information provided by patients, over the span of a few weeks. Texting patients, if permitted by physician practices, was also encouraged. If patients still had not responded, a letter was sent to notify them about scheduling annual physicals.

Discussion

Throughout the first period of sending out the dropped-patients report, the percentage of patients who were left phone messages (29.45% on June 9) was larger than that of the combined scheduled/already-seen percentage (26.45%). The new strategy to contact patients after June 9 helped lower the percentage of patients left messages to 25.50% while raising the scheduled percentage from 10.44% to 12.51% (Table 1). By the end of July, the trend had reversed, with the 28.87% scheduled/already-seen rate surpassing the 25.50% left-message rate (Table 2). PBACO’s assignment team and nurses, who organized report distribution and were the only ones using the new contacting protocols, demonstrated significant improvement in establishing patient contact through such special protocols/techniques. However, these PBACO employees were not granted full access to their assigned physicians’ patients—in some offices, they were relegated to purely a consultant role—and were only able to work with a smaller cohort of patients. The opposite was true for staff at physician offices, who worked with the majority of patients on the reports but generated slower progress, with a constant scheduling rate (categorized as “already seen”) of about 16% (Figure); the offices used no new methods of contacting patients. Therefore, the largest opportunity to retain patients through annual check-ups lies in improving office scheduling procedures by encouraging follow-up appointments to strengthen the PCP—patient relationship and preventing patients from being dropped in the first place. In the long run, offices can produce self-improvement and achieve enduring progress.

Many patients who were scheduled had not seen their PCP in more than a year simply because they hadn’t felt the need for a visit, and they only needed a phone call to remind them to make an appointment for an annual physical. Another predominant reason for dropping PCP assignment was change in the patient’s location, insurance, or choice of PCP, which accounted for 15.53% of the returned reports. Another 8.79% were patients who were either inactive or unavailable for scheduling or had no contact information and/or address in electronic health records (EHRs); 2.16% of patients could not be found in the EHR. Only 50 patients, 1.16% of the total returned, responded that they did not wish to return to their assigned PCP. It is highly possible that the remaining patients who were left a message, many of whom had been contacted by telephone at least 3 or 4 times to no avail and had been sent a postcard or letter, fell into this nonreturning category, although there is no definitive evidence to confirm so.

Nevertheless, the second month’s gradual pace of distribution and scheduling of the dropped-patient reports indicated that most progress was achieved during the first month. Even with various changes in protocols, ranging from repeated phone calls and letters to allowing nurses to schedule appointments, the scheduling rate improved by only 2% over the second month. The postcards and letters yielded a minimal response rate, although some patients did reach out to their physicians for scheduling, and re-calling patients only reached about 10% of those who were left messages. Most likely, the patients who were more easily reached had already been contacted and scheduled within the first month, whereas patients who were initially harder to reach stayed harder to reach and comprised the population of the reports returned in the later weeks. The future methodology of processing dropped-​patient reports may have to adjust for this possibility, perhaps by exploring alternative strategies in attracting patients back or reforming practice scheduling methods.

Much of the methodology for processing the dropped-patient reports is also applicable to high-cost/high-risk reports, including data collection, categorization, and analysis and the patient scheduling process. Although these 2 projects cover opposite ends of the patient health—cost spectrum, they require similar procedures and reports. Due to the similarity in how the reports are completed, future distribution of dropped-patient and high-cost/high-risk reports to physician practices can be synchronized for more coordinated and efficient execution, as well as for the convenience of the scheduling staff.

The use of dropped-patient reports was projected to save $1,892,094.96 (Table 3) for 2017. These savings were calculated using the latest available rosters and reports from all 3 payers. For each payer, the average per member per month (PMPM) cost of each payer’s population without the dropped patients and the average PMPM cost of the population with the dropped patients were calculated. The difference between the PMPM costs with and without the dropped patients was then multiplied by the panel size (with dropped patients included) and by 12 months. Each payer’s savings were then totaled.

Limitations

A significant limitation to the results included the 1564 patient reports (26.66% of the total) that had not been returned. More than a quarter of the reports were not completed because some practices in particular counties scheduled the patients on the reports at a slower pace, a few practices had staffing or EHR complications, and other practices had not granted scheduling access to assignment team members. Data from all of the reports that had not been returned may have been rolled over to the next quarter’s results and would be recorded accordingly. Another limitation is that patients who had been scheduled may have canceled or not attended their appointment. Such patients could be tracked in the EHR every so often by assignment team members or nurses.

The savings calculations also had several limitations. The attribution dates for each payer’s latest roster differed and are all dated just prior to the distribution of the reports (May 2017). Therefore, the estimated costs from each roster may not reflect the most updated cost per patient at the time when offices started scheduling the dropped patients. Also, the PMPM costs for the Cigna roster were risk adjusted, unlike the PMPM costs of the dropped patients. Nevertheless, the estimated savings should provide a general idea of the dropped-patient reports’ effectiveness in improving healthcare access at a stable or lower cost over the span of a year.

Projected Improvements

Future dropped-patient reports should focus more on innovative and alternative techniques to reach patients. Letters and postcards may more easily reach older retired Medicare patients, whereas texting and emailing may be more viable strategies for contacting younger working patients who are covered under commercial plans. Calling at later hours near the end of the workday may also be effective. In the next rounds of future dropped-patient reports, more time and resources should be invested into testing different approaches.

Conclusions

The dropped-patient reports successfully retained at least 1 of every 5 patients who had lost or were about to lose assignment to their PCPs. Scheduling dropped patients is a crucial initial step in maintaining a stable panel size and improving quality of care. As these patients start attending appointments with their PCPs, the next step is to ensure they are also seen more frequently with follow-up appointments. PBACO hopes to encourage its member physicians to schedule follow-up appointments for every patient before they leave the office. By improving the quality of care and forming stronger bonds between PCPs and patients, dropped-patient reports have potentially generated pecuniary benefits. With the lessons learned from the initial report rollout, subsequent reports will be distributed and processed more efficiently, with more room to innovate and investigate the means of reaching out to patients.Author Affiliation: Palm Beach Accountable Care Organization, Palm Springs, FL.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and statistical analysis.

Send Correspondence to: Nicholas Ma, Palm Beach Accountable Care Organization, 2326 South Congress Ave, Ste 2F, Palm Springs, Florida 33406. Email: nma@pbaco.org.REFERENCES

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2. Maciosek MV, Coffield AB, Flottemesch TJ, Edwards NM, Solberg LI. Greater use of preventive services in U.S. health care could save lives at little or no cost. Health Aff (Millwood). 2010;29(9):1656-1660. doi: 10.1377/hlthaff.2008.0701.

3. Beech BM, Cordier T, Happe LE, et al. Does a free office visit affect primary care-seeking behavior? a study of new exchange health plan enrollees in Mississippi. Am Health Drug Benefits. 2017;10(2):64-71.

4. Stowell C, Akerman C. Better value in health care requires focusing on outcomes. Harvard Business Review. September 17, 2015. hbr.org/2015/09/better-value-in-health-care-requires-focusing-on-outcomes. Accessed July 19, 2017.

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