At the Helm

What good is a value-based care network if patients can't access it?

by Laurie Sprung, PhD

One of our clients was approached recently by a large local employer that was looking to contract directly for employee health coverage. In the employer’s list of requirements for potential health system partners, patient access stood out as a clear priority. The employer expected health systems to offer:

"Same-day primary care appointments for acute conditions; three-day primary care appointments for any condition; 10-day specialist appointments; extended operating hours; extended urgent care hours; and a member website."

That’s a daunting list, but these days not an unusual one. It’s fair to say that “access” is now one of the critical characteristics that purchasers are looking for from value-based care networks.

Poor access means potential for poor outcomes

I’ve spent most of the last decade building clinically integrated networks (CINs), ACOs, and other value-based care programs. Although these now-maturing programs are increasingly fulfilling their purpose of improving the quality, coordination, and cost of health care, I find that many of them struggle with patient access challenges that diminish the integrity and effectiveness of the network.

When patients cannot even get in to see a provider, their inability to receive health care undermines the quality standardization work done in establishing and managing the value-based care program.

We interviewed the executive director of patient access at one health system in the Northeast who told us about a recent access shortfall he came across. A patient with mild chest pain tried booking an appointment with his independent cardiologist but was told that it would be a 10-day wait for an appointment. By contrast, the patient, who turned out to have advanced coronary artery disease, got a next-day appointment with a health system-affiliated cardiologist. “That patient got a stent later that day,” the executive director said.

In fairness, missing opportunities to intervene in severe cases is less common—most providers are well set up to triage emergent situations. But what is common is how negatively patients respond to being denied access—responses that undercut the benefits of the CIN or ACO in other ways. Patients may opt for higher-cost sites like the emergency department, even in non-emergent situations. Or, they may seek care outside of the network, resulting in fragmented or duplicative services.

Moreover, aside from the population health aspects, denying patients timely access to care also denies the health system revenue that could be realized today by better managing leakage.

The health system’s role in setting standards

After investing millions in value-based care programs, health systems can’t afford to let patient access challenges stand in the way of program effectiveness. But how can health system leaders ensure all network providers are adhering to requirements like the ones called out in the RFP?

Here are four keys we’ve found to improving patient access within value-based care programs.

1. Start with the health system’s employed physicians. The owned medical group is a great learning lab for patient access improvement, and positive results within the medical group can create the momentum and physician champions needed to rollout patient access standards more broadly.

2. Engage physician leaders from the broader network. When beginning to roll out to the value-based care program’s provider participants, health system leaders can apply the same approach used when setting up the network originally: engage a core group of physician leaders to create the network’s new patient access standards, like same-day appointments or weekend availability.

3. Develop flexible standards. In most cases, the set of standards in the broader value-based care program will not be as strict as those set for the owned medical group, but they should support the health system’s vision for access. Moreover, the health system should allow participating providers to determine how they will adjust their respective practice operations to meet the standards—the important part being the end result, and not necessarily the path that works for each practice.

4. Consider investing in assistance. Once the standards are set, the health system can measure the opportunity and determine what level of investment it is willing to assist participating providers in meeting the access standards.

Meeting the patient access demand

The patient access requirements demanded by the employer in my first example aren’t unique to organizations with significant purchasing power. The patient mindset is changing. And for health systems taking on value-based payment models or operating in a competitive landscape—which, these days, is virtually every institution—improving patient access can mean the difference between organizational success and failure.

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