Who could have guessed that merely tweaking the patient schedule could snowball into better chronic disease management and a nearly $13,000 increase in one physician's yearly revenue? Yet, that's exactly what Kurtis Elward, M.D., a family physician in Charlottesville, Va., has achieved with a planned visit concept he calls "asthma days."
Small Changes Reap Large Rewards
Focused Asthma Care Increases Revenue Flow, Improves Treatment
By Sheri Porter
4/14/2006
Late in 2003, in an effort to improve the quality of asthma care in his practice, Elward began reserving several half days a month for his patients with asthma so that he and his staff members could provide focused, comprehensive asthma care.
The result: "My charges for asthma patients were nearly $20,000 last year," said Elward. Before asthma days, he collected around $7,500 annually for asthma care.
Although Elward has seen an increase in his asthma patient census, the 30 additional patients he's now treating for asthma don't fully account for the better bottom line. "Essentially, I realized I was leaving money on the table and good patient care outside of my office, partly because I just wasn't seeing people on the recommended schedule," he said.
Elward is the AAFP's representative on the guidelines implementation panel for the National Asthma Education and Prevention Program, or NAEPP, a program initiated in 1989 by the National Heart, Lung and Blood Institute. He now schedules his patients with asthma to adhere to NAEPP guidelines that suggest severe persistent asthmatics should be seen four times a year; moderate persistent asthmatics should be seen three times a year; and patients with mild intermittent asthma should be seen once a year.
In addition to increasing the frequency of patient visits, Elward and his office staff pack more patient care into each asthma visit. "Because of the improved level of service, we now bill 80 percent to 90 percent of asthma visits as 99214's," said Elward. These visits previously were coded as Level 2 or Level 3 visits.
The concept also helps staff members focus. During asthma days, it's all asthma, all the time. Nurses don't bounce from a well child-exam, to a laceration, to a hypertensive patient and then to a patient with asthma who quite possibly had been sandwiched into the schedule with just enough time for the minimum standard of care, said Elward.
The result: "My charges for asthma patients were nearly $20,000 last year," said Elward. Before asthma days, he collected around $7,500 annually for asthma care.
Although Elward has seen an increase in his asthma patient census, the 30 additional patients he's now treating for asthma don't fully account for the better bottom line. "Essentially, I realized I was leaving money on the table and good patient care outside of my office, partly because I just wasn't seeing people on the recommended schedule," he said.
Elward is the AAFP's representative on the guidelines implementation panel for the National Asthma Education and Prevention Program, or NAEPP, a program initiated in 1989 by the National Heart, Lung and Blood Institute. He now schedules his patients with asthma to adhere to NAEPP guidelines that suggest severe persistent asthmatics should be seen four times a year; moderate persistent asthmatics should be seen three times a year; and patients with mild intermittent asthma should be seen once a year.
In addition to increasing the frequency of patient visits, Elward and his office staff pack more patient care into each asthma visit. "Because of the improved level of service, we now bill 80 percent to 90 percent of asthma visits as 99214's," said Elward. These visits previously were coded as Level 2 or Level 3 visits.
The concept also helps staff members focus. During asthma days, it's all asthma, all the time. Nurses don't bounce from a well child-exam, to a laceration, to a hypertensive patient and then to a patient with asthma who quite possibly had been sandwiched into the schedule with just enough time for the minimum standard of care, said Elward.
Organizing Asthma Days
When he set about his quality improvement project in late 2003, Elward's goal was to make asthma visits more efficient, more organized and more valuable to patients. His resolve stemmed in part from seeing colleagues struggle with how to make their asthma care systems more efficient.
A couple of patients that he'd referred to an asthma specialist further fueled his desire when they described to him the coordinated team care they'd encountered there. It was an "aha" moment for Elward. "I realized that the asthma specialist had less staff than I did, but that he was organized in the way he provided care."
Elward set the wheels of change in motion. He created an asthma team from among his staff members and assigned them to handle particular aspects of the patient visit in a streamlined fashion that works something like this:
A couple of patients that he'd referred to an asthma specialist further fueled his desire when they described to him the coordinated team care they'd encountered there. It was an "aha" moment for Elward. "I realized that the asthma specialist had less staff than I did, but that he was organized in the way he provided care."
Elward set the wheels of change in motion. He created an asthma team from among his staff members and assigned them to handle particular aspects of the patient visit in a streamlined fashion that works something like this:
- Check in. The front desk staff starts the process by handing the patient a self-assessment form. The patient completes the asthma control test survey in about 60 seconds.
- Nurse care. The nurse review and assessment averages two to five minutes and includes taking vital signs; asking questions about medication changes, refills and hospital visits; and administering a peak expiratory flow. Spirometry, when needed, adds another 10 minutes
- Physician assessment and exam. Elward spends an average of 20 minutes per patient. "If one person needs 10 minutes and another 30, it's still part of the same process of care, so we don't find ourselves getting behind," he said. He covers goal setting, treatment recommendations and an asthma action plan that serves to educate patients in self management.
- Distribution of teaching materials. The patient receives patient education materials that have been pre-assembled by a nurse who's attended the Asthma Educator Institute offered by the American Lung Association.
- Check out. The next visit is scheduled -- as determined by the NAEPP guidelines -- in a future asthma day slot.
Asthma Days: Advance Planning Helps Ensure Success
Kurt Elward, M.D., said he's seeing sustained improvement in his patients with asthma, and notes that his system of care is transferrable to other chronic diseases, such as diabetes, hypertension, heart failure or hypercholesterolemia. Elward offers these tips to physicians who would like to implement a program similar to asthma days in their practices.
- Review asthma care currently provided.
- Identify patients with asthma from billing records.
- Determine who's not been seen in the past three to 12 months.
- Set aside half days for asthma visits several months in advance.
- Send letters to all asthma patients explaining the asthma days' concept.
- Call patients and begin scheduling.
- Train staff in their individual roles during asthma days.
- Schedule follow-up visits according to national guidelines.
Planned Visit Benefits All Parties
Elward said the new system of care has a greater than 90 percent satisfaction rate on patient surveys. Patients also are now staying out of the emergency room. ER visits for acute asthma care among Elward's patients dropped from an average of eight per year to just one last year. That's good news for patients and for Elward because he doesn't get paid anything when a patient is treated in the ER.
Fewer ER visits also mean a significant savings to the patient's health plan, which could face an ER bill of around $3,000 for an asthma emergency. "There hasn't been a single insurance company that's blinked about providing the nationally recommended asthma care," and that's what asthma days enable us to do, said Elward.
The bottom line is that this system pays for itself, said Elward. There's a lot of talk about pay for performance these days, but "this is a way you can pay yourself for your own performance."
Fewer ER visits also mean a significant savings to the patient's health plan, which could face an ER bill of around $3,000 for an asthma emergency. "There hasn't been a single insurance company that's blinked about providing the nationally recommended asthma care," and that's what asthma days enable us to do, said Elward.
The bottom line is that this system pays for itself, said Elward. There's a lot of talk about pay for performance these days, but "this is a way you can pay yourself for your own performance."
Bottom Line Series