Urgent care group success via medical scribes

Kootenai Urgent Care LLC in Coeur d’Alene, Idaho, represents one of the largest components of North Idaho Family Physicians LLC, a group of 27 independent primary care physicians.

The urgent care group, formed in 1998, became a joint venture with a local hospital district in 2010. It was run as an independent physician practice managed by NIFP, but with a slight twist on your more traditional practices.

“We don’t get to control our patient volume necessarily because we don't schedule our patients,” said Adam Jones, CPA, MGMA member, then-chief financial officer of NIFP. “Our team can walk in and just be swamped with 60 patients that morning or it could be as little as five [patients]. We just really don't know day to day what that patient volume is going to be, which creates a unique challenge for our team.”

That patient volume issue became more pronounced in 2013, when the area began experiencing a shortage of physicians. Population gains from growth in the retirement community and an increase in student enrollment at the local community college also resulted in government payers as a percentage of the total payer mix growing.

“We were getting growth rates of 3% to 7%,” Jones said. “At the time we started looking at medical scribes [in fall 2015], we were having growth of about 5%.”

Increased industry and Kootenai County’s reputation as a tourist destination also were factors: “As the economy has recovered over the last few years we've seen a lot more tourists visit our area because of an increase in disposable income. So those are good problems to have” as a community, Jones said.

An increase in patient volume may have otherwise been manageable, but the group also faced a handful of other challenges simultaneously:

• Patient scores were seeing a decrease, which may have been attributable to many older physicians recently shifting to an EHR and facing new documentation burdens.
• The group faced physician turnover for the first time in about five years, which was handled initially by using locum tenens physicians, which was very expensive. To expedite the need for temporary providers, Jones lobbied the executive director to offer larger signing bonuses to help recruit new doctors and end use of locums providers sooner.
• Group practice leaders noticed signs of burnout amid increased overtime, support staff turnover and an increase in compliance and reporting requirements.

Initially, the group considered hiring NPPs to help alleviate pressure from these issues. But from Jones’ perspective as CFO, the growth in patient volume still was not enough to justify such a move as a budget-controlled expense – the practice “would lose money to take on additional patients,” he said.

This led to a serious look at using medical scribes, which many of the independent family practice physicians on the group’s board had already embraced. “It gave us some comfort level to start looking at medical scribes and what they offer,” Jones said.

“Obviously with the national shortages, it’s a lot easier to hire a medical scribe than a midlevel,” Jones said. “It’s a cheaper option and you have the ability to flex their hours, especially if you outsource that function: Raise their hours in your busy times, lower them during in your slower times.”

Another key consideration in weighing NPPs and scribes was provider compensation. The group paid providers based on production – adding NPPs would force them to share patients and influence productivity numbers that might upset physicians.

Going with scribes

With the added benefit of having someone dedicated to helping with documentation, the group decided to pursue medical scribes. Jones worked to pencil out the costs of implementing a program in house or via a third party. While more cost effective if handled in house, the group recognized that certain responsibilities could be shifted to a third-party entity to not tie up the group’s operations management leaders, who were already focused on the strong patient volume growth. Ultimately, the group identified an entity that was very experienced with the process that typically hired pre-med students and could also hire candidates from outside of medicine – in either case, those workers were trained within three or four months.

Next came the work to gain board support of the plan. A few board members already used scribes in their previous work experiences, so the board already had physician champions and a majority to support the move. Only two board members required further persuading so that the group could have unanimous approval of the move in fall 2016, as is customary for their decision-making.

Rolling it out

Despite unanimous board support and high expectations, the medical scribes plan was rejected unanimously by the employee physicians, who perceived it as a hit to their productivity ratio and expressed anxiety due to being more familiar with working with NPPs.

Instead of a wider rollout of the program, the group leadership compromised with employee physicians by starting the scribes program at a single clinic with a $10,000 buyout clause in the first year of the contracts – if it was deemed a failure, the group leaders agreed to go in a different direction.

Upon implementation, the employee physicians loved the addition of scribes. The physicians received extra support, were able to spend more time talking one-on-one with patients and were more productive, resulting in higher compensation in the first few months of the program. Another bonus: Physicians started leaving on time: Total hours worked decreased, and more providers were paid on productivity on a regular basis and bringing in revenue to offset the cost.

With one clinic’s success, other clinics then began to hire medical scribes and the group was able to reap the full benefits of the plan.

The results

• Average wait time in the lobby stayed unchanged in the coming year. “Between 2016 and 2017 patient volume grew 7%, so we were able to absorb that entire 7% and what we were doing historically,” Jones said.
• The average room time and average door-to-door times both dropped three minutes. “This may not seem like very much, but in an urgent care setting, you live and die by workflow and time — three minutes here, three minutes there really adds up over the course of the day,” Jones said.
• Total provider hours decreased, from 21,327.41 hours in 2016 to 20,778.23 hours in 2017. In the same period, encounters per full-time-equivalent (FTE) provider increased by 500, resulting in increased profitability and revenue.
• Kootenai Urgent Care’s net promoter score rose two points in the same period, which Jones credits to physicians “spending more time with the patient than on their iPad,” which helped the perception among patients that they were receiving better quality of care.

Key takeaways

• Jones recommends that practices identify the length of time it takes providers to chart before evaluating a different strategy.
• Reviewing the consistency of provider coding will help improve both physicians’ documentation and help medical scribes succeed in a new program.
• Regardless of specialty, clinics need to see more patients for it to be financially viable. A financial model that supports your practice’s operational model and subspecialty is needed.
• Know the impact a program will have on your provider compensation model to help allay fears of change among your physicians.