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Thursday, November 1, 2012

Should you offer extended office hours?

A recent study published in the Annals of Family Medicine suggests that offering extended office hours, such as evening and weekend hours, reduces health care expenditures without adverse effects on mortality.

Researchers analyzed data from more than 30,000 individuals responding to the 2000-2008 Medical Expenditure Panel Surveys, an annual national survey of health care use and costs, who had reported access or no access to extended hours through their usual source of care in two consecutive years. Total expenditures were 10.4 percent lower among patients reporting access to extended hours in both years versus neither year. After adjusting for year-two prescription drug expenditures and office-visit-related expenditures (e.g., diagnostic testing), researchers found that the decrease in health care expenditures was 5.7 percent and 4.3 percent, respectively. This finding supports the notion that physicians' clinical choices, such as choosing less expensive or generic medications over more expensive ones or choosing to forgo discretionary testing, also have a great influence on expenditures.

Advice from the real world

Extended office hours may offer additional benefits as well, according to an article in the FPM archives written by members of Primary Care Partners, a group of 23 family physicians and pediatricians in Grand Junction, Colo. After establishing an after-hours clinic in 1998, the group saw increases in practice revenue, patient satisfaction, and physician satisfaction. "The after-hours clinic has been the most successful innovation in primary care delivery in our community in recent memory. Patients love it. Office staff love it. Physicians love it. Insurance companies love it. Hospitals can’t compete with it. And family physicians can do it really well," said the authors. They offered the following pointers to other practices considering an after-hours clinic.

1. Calculate how many patients you need to see in order to break even. The physicians of Primary Care Partners needed to see 12 patients per evening and 31 patients per weekend day. Early on, their patient volume was lower than that, but it gradually grew to more than 50 patients on week nights and 60 to 100 on weekend days.

2. Expect patient volume to vary by day of the week and season of the year. For example, the practice averaged 123 patients on Saturdays during winter flu season, compared with 73 patients on Saturday during the summer.

3. Set up your after-hours fee schedule using a slightly higher conversion factor than for your regular fee schedule. Primary Care Partners was able to negotiate a facility fee with its major insurers by showing that their after-hours clinic reduced ER utilization rates.

4. Ensure adequate staffing. For Primary Care Partners, after-hours staffing initially consisted of two receptionists, one CNA/nurse, one X-ray/laboratory technician, and one physician. The practice also hired a nurse administrator to run the clinic and to work shifts when staffing was difficult. One of the practice owner-physicians served as medical director. Staffing grew with the revenue stream.

5. Market the after-hours clinic within your practice and with other local physicians to help it grow quickly. Local insurers may encourage members to use your facility or even help with some start-up costs if they view it as a less expensive alternative to the emergency room. Primary Care Partners also set up an emergency room “dysutilization” program, under which a staff person contacts patients who have gone to the emergency room for problems that could easily be managed in the clinic and informs them of the practice's after-hours service. The practice received a case management fee from some insurers for this service.

For more information, see Quackenbush J, Shenkel R, Schatzel V. Creating a successful after-hours clinic. Fam Pract Manag. January 2004:39-42.

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