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When Cumberland Medical Associates in Vineland, NJ, started signing managed care contracts in the early 1990s, office manager Barbara Yacovelli noticed availability requirements in some contracts that could be difficult for the practice to meet. "They wanted us to see patients within three days for routine matters and within 24 hours for urgent matters," says Yacovelli.
In order to meet those needs, as well as the needs of patients who found the 9 a.m. to 5 p.m. hours inconvenient, the two-office internal medicine practice decided to change its hours. Now, both offices are open from 8 a.m. to 8 p.m., Monday through Thursday, and 8 a.m. to 6 p.m. on Friday.
It is a growing trend, says Donald Fisher, PhD, CAE, chief executive officer of the American Medical Group Association in Alexandria, VA. "Our members are finding they have to both extend hours and expand locations in order to meet the needs of patients," he says. "We are a society that is getting more used to convenience, and health care is not exempt from that."
Previously, if the doctor wasn’t in, patients would go to the emergency department, Fisher says. "Now, that isn’t necessary or acceptable. Groups find they have to stay open nights and weekend hours."
The trend was definitely spurred by the advent of corner clinics that operate with extended hours and no appointment, Fisher adds. "They were a wake-up call for our members."
Cumberland’s changes have resulted in happier patients and an improved ability to meet managed care access requirements, Yacovelli says. "We have always had regulations about the need for referrals, and patients would see us as the bad guy. This is a way for us to be more user-friendly."
The results were similarly positive at the six offices of Southwest Asthma and Allergy in the Houston area. After doing a patient satisfaction survey in 1994 in which 40% of respondents stated they didn’t think the hours were convenient, the clinics opted to change hours. Each office chooses its own days, but all are open late at least one day per week, and some open as early as 7 a.m., says practice administrator John White. Since then, patient satisfaction ratings have gone up, staff are pleased, and White says he can’t think of a reason why all practices don’t extend office hours.
While he can’t point to any contract wins resulting from the change, White says that since the program was implemented, it has played a positive role in credentialing and audits performed by payers. "We haven’t had a score of less than 99 out of 100 since this happened," says White, "and I think that this is part of the reason."
The flexible schedules of both of these practices did have associated costs. For example, Yacovelli had to increase staff by at least 30%, she says. "We have four shifts they start at 8 a.m., 9 a.m., 10 a.m., and 11:30 a.m."
At Southwest Asthma and Allergy, the staff that were added to cover the flexible hours also increased total employees by about one-third from about 40 full-time staff before the change to 56, currently. But White has kept the costs down by opting to hire only part-timer employees. "We don’t have to worry about benefit costs then," he says.
Staff have adapted to the change well partly, White says, because they were consulted ahead of time about the change. Most now have Friday afternoons off, and all of them feel a sense of relief that the patient load is more steady all day long. "Before, we would have these times when we were bogged down with patients," he explains. "There would be full waiting rooms and a lot of noise and confusion. [The new hours] allow us to spread our patients’ visits out more."
No staff member has left because of the extended hours, he adds.
The five doctors and the nurse practitioner all understood the need to make the change, says White. "It is a revenue issue for them. If we didn’t do this, we risked losing patients to competing practices that were more flexible," he says. This was particularly true of the practice’s pediatric patients. "Kids are in school, and there are limits as to when they can come in."
Yacovelli’s medical staff also noted that they were working harder and making less money with the advent of managed care. The only way to make up the difference was to attract more patients and ensure that patient satisfaction remained high. "We have to consider the convenience of our patients," she says. "Then we can consider our own needs."
Southwest Asthma and Allergy still closes for lunch in order to allow the doctors and administrative staff to get paperwork done, but the phones are answered by staff, White says. "We make more appointments during lunch than any other time," he says.
Big companies and teachers all have limits on when they can make personal calls, White explains. By keeping the phone lines open, he can accommodate those patients.
There is an added benefit to seeing more patients later in the day, White adds. There is more quiet time in the morning. "Our evening appointments fill up months ahead of time," he says. "We always have more time in the morning to get other things done and for our own staff to see their doctors or dentists."
The program has been so successful that White is considering weekend hours, too. The staff may not take as kindly to this change, but he says he thinks he can sell it to them by offering another day off, or perhaps by floating staff so that no one works more than one Saturday per month.
Cumberland has already started the hiring process for two new physicians so that the practice can remain open on Saturdays. "The majority of offices around us have very rigid hours," she says. "We like to give our patients more options."
While White only advertised the hour changes in the office, Yacovelli touted the new hours in the newspaper, in the Yellow Pages, and in the office to patients directly as they made follow-up appointments. While those methods added some small costs to the program costs that will vary from city to city they also brought in more patients, which was the aim of the extended hours, she says.
The "doc in the box" clinics already keep late hours to attract patients, White says, and they fill a gap not met by traditional practices. Before, the only option for a patient was to wait or go to the emergency department for an urgent problem or to give up a day’s pay or vacation time in order to see a doctor at his or her convenience.
But society is changing, and White says it is possible that as fewer patients make appointments for the 9 a.m. to 12 p.m. time period, his practice hours could shift completely. "There are practices that open at 1 p.m. and close at 9 p.m., and they do just fine," he notes. The brother of one of his colleagues in Dallas keeps his practice open until 10 p.m. every night, White says. "I don’t think we are quite ready for that yet."
John White, practice administrator, Southwest Asthma & Allergy Associates, Houston. Telephone: (713) 499-9505.
Barbara Yacovelli, office manager, Cumberland Medical Associates, Vineland, NJ. Telephone: (609) 327-0880.
Donald Fisher, PhD, CAE, executive officer, American Medical Group Association, Alexandria, VA. Telephone: (703) 838-0033.