Abby Burns (00:11):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. I'm Abby Burns. If you ask any healthcare leader what the top challenges in our industry are, you can guess some of the answers you're going to get. They're going to talk about affordability, they're going to talk about workforce, and they're going to talk about patient access. Providers in particular have been trying to improve patient access for years, and they've made a lot of investments to make that happen. Think about the virtual care infrastructure that we have today compared to pre-pandemic. Think about the ambulatory networks organizations have built out, and yet if we look at the numbers, these big swings haven't translated to meaningful improvements in access at scale, and in some cases things have actually gotten worse.

(01:03):
This week, I want the medical group lens, because medical groups are on the front lines of provider strategies to try, and improve access. So, I've invited Advisory Board physician, and medical group expert, Mahaya Walker, to help us unpack why our efforts to improve patient access to care are falling short, and how medical groups can think, and act differently to move the needle. Hey, Mahaya, welcome to Radio Advisory.

Mahaya Walker (01:27):
Hey, Abby. Thanks for having me.

Abby Burns (01:29):
Mahaya, one of the big areas of focus that pretty much any provider organization has on their strategic priority list is improving access to care, and we've seen a lot of investment made in recent years with that goal in mind. Everything from virtual care platforms to patient navigators to wider outpatient footprints, and everything in between. My first question for you is a two-parter. First, what are we actually talking about when we say access to care? And second, are these investments actually working? How are we doing at improving access?

Mahaya Walker (02:09):
For the sake of this research in today's conversation when we say access, we are talking about the ability of health systems, and medical groups to offer patients timely, and adequate care. We're also talking about it in the ambulatory setting, which is where most systems focus their access strategy. And then lastly, we primarily focus this research on primary care, but I would also say that most of this research, if not all of it, can also be applied to specialty care as well.

Abby Burns (02:37):
And when you say this research, you were talking about the research that you, and your team have conducted over the past year around improving access.

Mahaya Walker (02:45):
Absolutely.

Abby Burns (02:47):
So, what did you find? How are we actually doing as an industry at improving access to care?

Mahaya Walker (02:51):
To improve access, historically, medical groups have been prioritizing increasing appointment availability. The issue is that approach isn't working, and we know it's not working by looking at appointment wait times. So, AMN Healthcare conducts a survey every two years, and from the most recent edition we saw that from 2017 to 2022, there's actually a decrease from 29 days to 21 days for primary care, but across all the four specialties that they track, wait times actually went up. Additionally, in a more recent survey from 2024 from ECG management consultants, they also tracked wait times this time across nine specialties, and in this case, wait times went up in every single case, and it ranged from 20 days to 68 days. So, the average specialty wait time sits at about 38 days.

Abby Burns (03:46):
So, just to say that again, if we measure access by appointment availability time to next appointment, primary care access has been getting better in recent years.

Mahaya Walker (03:54):
It's getting better, but it's still not great.

Abby Burns (03:56):
Still not great, important call out. But specialty care access is actually getting worse to the point where it's up to several months for some specialties.

Mahaya Walker (04:04):
Correct.

Abby Burns (04:06):
My other obvious patient implications here, and I think we all have stories of ourselves, or loved ones trying to schedule a medical appointment, and being told, great, we'll see you months from now when really we'd like to be seen much sooner. But I want to think about this from the provider lens for a second, because we know that providers need to walk this very narrow margin mission line. Things are really tight right now. If we look at health systems, for example, the average health system operating margin right now is 1.2%. It's tight, and yet the fact that this continues to show up at the top of providers priority lists when they have so many other headwinds to contend with, tells me that there's probably a business imperative here, too.

Mahaya Walker (04:48):
That's absolutely correct, and there's an obvious line between appointments, and the revenue that they generate for medical groups. But medical groups, as you mentioned, as you alluded to, are under heavy financial strain. So, in 2024, total expenses per physician outweighed total revenue per physician by about 33%. That means costs outweighed revenue by 33%. Additionally, we're seeing a decline in reimbursement rates. On Medicare alone, there's been a 29% decline in physician payment from the time span of 2001 to 2024. And then there's also been an increase in claim denial. So, provider organizations spent an estimated $19.7 billion a year just to adjudicate with payers against claims, and those are just a few examples, a few data points to kind of highlight the financial pressures that medical groups are facing. So, you really get the point that these financial pressures are just as much of a catalyst for the emphasis on appointment availability as is patient demand.

Abby Burns (05:50):
Yeah. Yep, that makes sense. It is the way that you get the revenue that you rely on in order to operate the business. And Mahaya, providers have made, like we said, a lot of investments in the name of improving appointment availability, but as you just told us, things aren't really getting better, in some cases they're getting worse. So, clearly something here isn't really working. What are we getting wrong in the way that we think about improving access?

Mahaya Walker (06:16):
Yeah, we asked ourselves the exact same question. It's honestly why we did such a deep dive into this topic with this research, we're hardly moving the dial on appointment times, and in some cases we're going the wrong direction. That tells us that an access strategy focused solely on appointments isn't solving this because appointments are the wrong metric. With that approach, people are taking too myopic, and too specific view of the problem.

Abby Burns (06:43):
I'm reminded of the expression there's only one way to eat an elephant, and that is one bite at a time. In this case, the industry has said access is such a gnarly problem to solve. Let's try, and break it down into component pieces. Let's focus on time to next appointment, even time to third next appointment to try, and make this measurable. What you're saying is we might've swung too far, and focused on too narrow of a metric to solve this problem. So, if trying to improve appointment availability isn't moving the dial, what should providers be aiming at instead?

Mahaya Walker (07:19):
There's two ways to look at it. One is at the organizational level, there are more goals for access that your organization should have beyond just appointments now. So, consider a few other goals such as increasing patient loyalty, reducing out of network referrals, or even succeeding in value-based care. These are things that aren't going to be solved by reducing time to third next available appointment.

(07:44):
And then I also look at the individual level. So, for patients, it's not appointments that they're fundamentally seeking, it's access to care, so getting their care needs met, whether that's through an appointment, or any other way. And then for providers, they manage all of the work that goes into managing care for their patients, appointments just being one facet of that work. So, instead, we should be looking at provider availability, and this shift to provider availability as the new access standard helps to meet your organization's business needs, your patient's expectations, as well as your provider's workflow demands. So, it's not just appointments anymore. It's this combination of both appointments, and non-appointment forms of access.

Abby Burns (08:29):
Mahaya, you bring up such a good point, which is that we have more modality, more ways to access care now than just appointments. I have to say. I'm guessing that antennae went up for any clinicians listening, any clinical leaders listening who hear you say provider availability, and non-appointment access, and they interpret that as Mahaya is saying, we should be giving patients their doctor's phone numbers, which I'm guessing is causing some heartburn. I'm guessing that is not what you are suggesting, but how would you correct that?

Mahaya Walker (08:58):
Yeah, that is absolutely not what I'm suggesting. You should not give your patients your phone number. When I say non-appointment forms of access, some examples of that are the work you're already doing, responding to patient portal messages, the care coordination between other members of the care team, or even other providers. It's patient education, it's remote patient monitoring. These are all forms of access that go well beyond just the patient appointment.

Abby Burns (09:24):
It's really interesting, because a lot of times we hear something like patient navigation, and we think of it almost as a population health play, and what you're saying is it doesn't need to only be considered as part of a population health strategy that is actually part of an access strategy, even in potentially a fee-for-service environment. It's not limited. The other thing that you said, Mahaya that jumped out at me was your access strategy needs to serve the needs of your business, the needs of your providers, and of course the needs ultimately of your patients, which feels like a hard balance to strike. So, I want to dig into each of those, and maybe we can start with the needs of the business.

(10:02):
One thing that comes to mind here is essentially we know that filling appointment slots is important from a revenue standpoint, right? And you told us exactly why. What do you say to leaders who are concerned that shifting focus away from appointments to things like patient navigation, or answering portal messages, some of these other things that they don't necessarily get paid for. That might mean getting fewer feet in the door to fill their appointment slots.

Mahaya Walker (10:30):
First, I'd say, let's recognize that systems are already quote-unquote "paying" this cost of access for this current approach. It's leading to more burnout, reduced provider satisfaction, and this is huge strain on resources.

Abby Burns (10:44):
I think that is such an important point.

Mahaya Walker (10:46):
Second, we're not arguing for a shift away from focusing on appointments, but instead we're arguing that we need to broaden the aperture beyond just appointments. But when it comes to business needs specifically, it's also about recognizing that not all appointments are created equal. So, we need to prioritize, or even recalibrate our attention on appointment types that are aligned with the organization's strategic access goals. To quote one of the chief medical officers that we spoke with, when every visit is a priority, then nothing is a priority.

Abby Burns (11:20):
You have to know that I'm going to ask what does it mean for an appointment type to be aligned to the strategic goals of the business? Can you explain that for me?

Mahaya Walker (11:28):
I want to bring it back to this concept of expanding your access goals beyond just approving appointment availability.

Abby Burns (11:34):
Okay.

Mahaya Walker (11:35):
So, for example, if succeeding in value-based care is a goal for your organization, annual wellness appointment should take priority on your provider's schedules. Or if you have a goal of reducing out of network referrals in network referral visits, you need to take priority.

Abby Burns (11:50):
Can I share a concern here?

Mahaya Walker (11:51):
Yeah.

Abby Burns (11:52):
I think when we're talking with provider organizations who are trying to stay financially afloat, a big part of, in particular their growth strategy is we are trying to get more commercial volumes in the door.

Mahaya Walker (12:03):
Yes.

Abby Burns (12:04):
The risk I hear with this strategy is it could open the door for provider organizations to essentially cherry-pick, "Hey, we're going to prioritize appointment slots for commercial patients over Medicaid patients." How do you square that?

Mahaya Walker (12:17):
It's about balancing the needs of the organization alongside the needs of your patients, and so you're prioritizing certain appointment types, but that doesn't mean you're neglecting all other appointment types either.

Abby Burns (12:27):
Yeah. Back to the margin mission line, are you really improving access if you're only improving access for a subset of patients? I think a lot of organizations would say, no.

Mahaya Walker (12:36):
No, correct.

Abby Burns (12:38):
Value-based care example I think is really helpful. If you have a goal around succeeding in value-based care, prioritizing that annual wellness visit is going to be really important. What's another example?

Mahaya Walker (12:48):
One good example of this comes from a mid-size health system we spoke to in the Southeast. As part of an ACO, they had a business need to prioritize post-discharge appointments. So, they implemented the tight, loose, tight framework to hardwire post-discharge appointments into their PCP schedules.

Abby Burns (13:06):
Mahaya, the way you just said, tight, loose, tight, makes me think it's an industry term that folks will know, but for those of us who don't necessarily recognize it right away, what is that?

Mahaya Walker (13:15):
Tight, loose, tight is about give, and take. It's being tight, and rigid where you need to be, but also being loose to allow for flexibility.

Abby Burns (13:24):
I'm guessing it's an operational tool to say, how can we hardwire workflows in ways that make our business run well while allowing for our staff to be human, and have some autonomy in the way they practice?

Mahaya Walker (13:35):
Totally. So, for this org, they were tight by mandating that all PCPs hold at least one slot per day for post-discharge visits, but then they were loose by letting providers choose where those blocks go on their schedule, and then tight again by putting a process in place that flips any unused slots. So, if a post-discharge slot goes unbooked 48 hours before the scheduled appointment, those are flipped, and made available for other appointment.

Abby Burns (14:02):
That speaks exactly to the concern of does a switch to provider availability mean we're not going to get feet in the door? This is a great example of how you mitigate that concern.

Mahaya Walker (14:10):
Absolutely, and avoid wasted capacity.

Abby Burns (15:14):
I feel like I have a good sense now for how to support the needs of the business in making this transition from appointment availability to provider availability, but frankly, none of that is possible, or even worthwhile if we're just exacerbating existing frustrations that our provider workforce is already feeling. So, let's talk about how we make this work for providers. You already told me you're not suggesting everyone handed their number out to their patients. How do we increase provider availability without burning out our doctors?

Mahaya Walker (15:46):
For providers, this is about right sizing their role so that they can focus top of license. So, now we're talking about provider workflow, Abby. So, most of us have heard how overbearing the administrative load can be for providers, but we wanted to quantify it, and so we did, and in our analysis of physician time, the time they spend on administrative tasks, we found that three tasks are leading the charge on the administrative burden. Those three tasks are clinical documentation, prior authorizations, and in-basket messaging. On average providers spend 161 minutes per day on clinical documentation, 159 minutes per day on prior auths, and 49 minutes per day on in-basket.

Abby Burns (16:30):
Okay, my mental math is not that fast, but that is several hours.

Mahaya Walker (16:33):
That's several hours. When you combine all three, that's about six hours per day on only these three administrative tasks. So, this is where we decided to place our focus in terms of right sizing the provider's role.

Abby Burns (16:47):
Yeah, I'm so glad that you went there, Mahaya, because we know that administrative burden is such a huge driver of burnout for physicians, for apps. This is also an area where provider organizations have done a lot to try, and reduce the amount of time that providers are spending so that they can spend more time with patients. Where have we seen progress here, or what are some strategies for success?

Mahaya Walker (17:09):
At the highest level, it's about putting ceilings on how much time providers are spending here, so putting guardrails into their workflows to prevent documentation, prior auth, or in-basket from taking over their days. So, we've published some great case studies on each of these, and highlighted some orgs that have made significant progress with each of them.

Abby Burns (17:30):
So, let's take one of these as an example, Mahaya, because you mentioned clinical documentation, you mentioned prior auth. You mentioned in-basket messaging, all huge areas. If we start with clinical documentation, what does it look like to move the needle here?

Mahaya Walker (17:42):
So, with clinical documentation, the top line is that you have to deploy documentation solutions that save provider time, both writing, and reviewing clinical notes, both steps. So, as you mentioned, there's a lot of innovation going on in the clinical documentation space. We heard a lot of really cool use cases with AI in particular that have shown promise, but what we have found is that some of these tools are helping one part of the problem, and exacerbating another. Specifically, many of these tools are targeting the time it takes providers to write the note, but oftentimes, those same solutions are inadvertently increasing the amount of time it takes for providers to review the note. So, you have to make sure your solutions are addressing both sides of the problem.

Abby Burns (18:26):
Mahaya, this is, I think, a really good example of a point that our colleagues on our AI research team make a lot, which is if you're just imposing AI, or digital tools on analog problems, and not actually solving the underlying workflow challenges, you're not really solving the problem.

Mahaya Walker (18:43):
With clinical documentation there's three quick tactics I'd suggest. The first is to tackle the unorganized note templates that are often plaguing providers. You want to streamline standardized templates to avoid over documentation. The second is where AI comes in. You want to strategically deploy AI to avoid exacerbating what we call note bloat, so it's like information overload in the clinical note, and the last is to establish built-in support systems for your struggling providers. If you take all three of these tactics, we estimate about a 38% time savings potential per clinical note.

Abby Burns (19:18):
That's pretty meaningful.

Mahaya Walker (19:19):
Yeah, I'd say so.

Abby Burns (19:21):
Okay, so that is clinical documentation. Another huge area we hear about is prior auth, and I would say this is a topic that is getting a lot of focus in the industry right now as a whole. What are some solutions you're seeing there?

Mahaya Walker (19:33):
First could not agree more. This was probably the biggest touchiest pain point that came up across our calls. The thing with prior authorization is that providers are involved. Where they get involved is far downstream in the prior auth process, so their time is often spent appealing prior auth denials. It's a lengthy, very time-consuming process, with them often on phone calls with payers for these peer to peer reviews. The key with prior authorizations is to intervene upstream in the prior auth process to help prevent those denials in the first place, so you're reducing the provider's role downstream. Our strategies here actually focus on the role of other members of the care team to increase that upstream workflow efficiency, specifically three steps here again, we want to use denial data to target our prior auth solutions, and map those common denials back to the prior auth workflow. You then want to centralize your prior auth teams to help consolidate resources, and then you want to take it a step further even to create specialized prior auth teams to help build that expertise, and knowledge sharing with your staff.

Abby Burns (20:42):
Mahaya, what I love about this example is one, it's not only speaking to, one, of the biggest pain points that we hear about, but two, I think this is such a helpful way to make it tangible that increasing provider availability doesn't have to mean changing what a provider does. These tactics that you're talking about involve other members of the care team, and changing other parts of the workflows that then have trickle-down effects on the way a provider is spending their time.

Mahaya Walker (21:06):
And actually with prior auth, we actually see the greatest time-saving potential, even more so than in basket, and clinical documentation, and it's because this is where there is the greatest opportunity to reduce the provider role.

Abby Burns (21:20):
What is the time-saving that we see for prior auth?

Mahaya Walker (21:22):
We're looking at almost 58% less time spent per prior auth with these solutions.

Abby Burns (21:27):
Wow, that's so much time-saving On the provider side. I mean, I know we started off saying it's up to six hours a day, or more that providers might have to spend on some of these tasks. That's a meaningful reduction in that number.

Mahaya Walker (21:40):
A lot of time-saving potential, but remember our push towards provider availability as that new access standard. With that in mind, it's important not to fall in the trap of thinking that all these time savings should go solely to adding more appointments. Provider savings can also go to those non-appointment forms of access, or can simply go towards giving your providers their lives back.

Abby Burns (22:02):
Yes, reducing pajama time.

Mahaya Walker (22:04):
Yes. Reduce the pajama time. We spoke to one chief physician executive about what to do with the provider time savings, and his response was that first, and foremost, they want to simply give providers time back in their day. They want to make their day-to-day more manageable, and for him, this was about physician sustainability, and retention, and further, it was a way to encourage some providers, a lot of providers in their instance, who had reduced their hours to help encourage their return to full-time in a way that could be more manageable.

Abby Burns (22:36):
This speaks to where you started when we were talking about provider availability with needs to support the needs of the business. It also needs to support the people that are delivering care, and when done together creates the kind of access capacity that ultimately serves patients.

Mahaya Walker (22:52):
Absolutely.

Abby Burns (22:53):
Mahaya, as we bring this conversation to a close, I want to sort of address the fact that attacking a problem like access is hard. We've hopefully made it a little bit easier by giving the framework of increasing provider availability as the target here. What would you recommend people take away as an action step?

Mahaya Walker (23:15):
I'd say start with metrics. If your access metrics already capture a fair amount of non-appointment indicators, give yourself some credit you've already adopted, or at least on your way to adopting provider availability as the new access standard. And if your access metrics are all appointment centered, start to think through what other access goals matter to your organization, and what access metrics you should be tracking related to those goals. But the metrics you're using to track success with access are going to tell you a lot about where to start.

Abby Burns (23:45):
Well, Mahaya, thank you for coming on Radio Advisory.

Mahaya Walker (23:48):
Thank you so much for having me.

Abby Burns (23:54):
When it comes to improving patient access, providers need to hold two things at the same time, meeting the needs of their business, and protecting the sanity of their providers, and if you do those two things well, you'll make patient access better. We're going to be talking about all of this, and more at our upcoming Physician Roundtable in DC. We'll include links to that, and to our broader patient access research in the show notes because remember, as always, we're here to help.

Chris Phelps (24:22):
Here's what our advisory board research team is watching this week. Over the past two weeks, two federal documents have been released that healthcare leaders should be aware of one in the legislative branch, and one in the executive branch. First, on May 22nd, the House of Representatives passed the bill known as one big beautiful bill. An amended version of the bill initially proposed a few weeks ago by the House Energy, and Commerce Committee. Abby gave an overview of the committee's initial proposal in our episode released on May 13th. Remember, this is the bill that aims to finance the Trump administration's agenda, and curb federal spending primarily through orchestrating more than 600 billion in reduced Medicaid spend over the next 10 years. By, and large, the healthcare provisions that were proposed in the initial bill made it through the house vote, either unchanged, amplified, or accelerated. I'm not going to talk through everything that made it into the bill that ultimately passed the house.

(25:23):
Instead, I encourage you to read our daily briefing team's comprehensive overview that's linked in the show notes, but I know it can be hard to keep track of where things stand, so let's do that. One big beautiful bill again has passed in the house, and includes the major healthcare provisions It began with. Now it has to go through the Senate where we do expect to see changes. The Senate is aiming to have a final bill ready to put on the President's desk by July 4th. In their intervening month, we expect to see a lot of advocacy on the Hill with healthcare leaders like yourselves, trying to communicate the real life first, second, and third order impacts of such widespread reduction in Medicaid coverage. That's the first document to be aware of from the legislative branch. Also, on May 22nd, the MAHA Commission led by RFK Jr released the first MAHA Commission report called Making our Children Healthy again.

(26:18):
Remember, MAHA stands for Make America Healthy Again, and is the name given to the de facto movement around RFK Jr.'s Healthcare Agenda, as well as the Inter-Department Presidential Commission formed in February that is dedicated to addressing childhood chronic diseases. When I say Inter-Department, it includes representatives from the Department of Agriculture, Housing and Urban Development, education, the National Economic Counsel, the Office of Science and Technology Policy, FDA, CDC, NIH, and More. The first report as expected focuses broadly on documenting the state of children's health, and the contributing factors to what it calls the declines in children's physical, and mental health. It identifies areas for the commission to target in its forthcoming strategy, which will be called the Make Our Children Healthy again, strategy expected to be released within the next three months. These include a number of areas that fall outside the primary control of the healthcare system, like ultra-processed foods, forever chemicals, declining physical activity, and the increasing rise in screen time, but it also points to the increased utilization of medication, including concerns around overprescribing, and vaccine schedules as an area for further review.

(27:32):
Here's the other thing to have in your radar. The report aims to undermine scientific literature saying it is too often subject to, quote, "corporate capture", putting, for example, to the high volume of clinical trials that are funded by private industry compared to US federal agencies like the NIH. I would point out that the administration recently proposed to cut the NIH budget by 40%

Abby Burns (28:21):
New episodes drop every Tuesday. If you like radio Advisory, please share it with your networks, subscribe wherever you get your podcasts, and leave a rating, and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Abby Burns, as well as Ray Woods, Atticus Roche, and Chloe Bext. The episode was edited by Katie Anderson with technical support provided by Dan Tyag, Chris Phelps, and Joe Schrum. Additional support was provided by Leon Elston, and Aaron Collins. We'll see you next week.