In Houston, VP For Health Advancement Unravels Process Challenges
At Healthcare Innovation's Texas Summit in Houston on Monday, July 18, Editor-in-Chief Mark Hagland conducted a provider spotlight with Randal Weber, M.D., associate vice president for healthcare advancement at the University of Texas MD Anderson Cancer Center. Hagland and Weber discussed the important initiative Weber is helping to lead in order to improve response times from inside his organization when new patients who have never been treated before at MD Anderson, as well as patients previously seen, come into the system to be scheduled for diagnostic appointments and procedures.
Hagland initiated the discussion by asking for background on the situation at the cancer center. Weber said, “On average, it takes a new patient from their first contact with us, the median time to when you're sitting with providers is 22 days—that's way too long. If you have cancer and you're newly diagnosed, there's nothing else going on for you and your life and caregiver.”
He added, “We call this ‘the whitespace’—between that first call to one of the patients after seeing a provider, there is a period of anxiety and uncertainty, everything else in your life falls away once you have a diagnosis of cancer. So getting patients in expeditiously and having an effective first appointment is so important, for a sense of well-being, but also getting treatment underway. This really resonated with me because from my experience in the head and neck program, I was one of those leaders, and our patient lag time got out to 15 days. I felt for the patient that was inappropriate, but we also had a lot of competition in the Houston area.”
Next, Hagland brought up process issues and underlying tasks associated with getting patients seen and treated. Weber explained that after the patient makes the call and the diagnosis or disease is determined and how to fix it, financial planners come into play. If the patient is in network, it is pretty quick to get approval. If the patient is out of network, or needs a primary care physician’s (PCP) approval, it automatically links into the process of when the other aspects of onboarding can begin. If the patient is out of network completely, they need to be given information quickly so they can seek care elsewhere because they are very unlikely to be treated at the cancer center because out of pocket costs would be huge.
“Then we have to access more information. If there are medical records and radiographs and pathology, we've got to start collecting that right at the very beginning. If it's a new patient previously treated, we don't need a lot of records,” Weber added. “If we have a clinic list from a specialist, it tells us the diagnosis and we can refer that patient to the appropriate healthcare team.”
Regarding PCPs, Weber said, “Some PCPs don't even understand that process. And I'm not sure if they haven't referred patients to such specialists or specialty hospitals, but that can be a real pain. So what we've done is try to partner with the patient—your PCP is going to listen to you more than they might listen to us. And then if you hit a roadblock, the patients contact their insurer, so that they can get involved and get the PCP to provide a referral because we can't even begin the process of onboarding them without the PCP or for financial clearance. And after we know which clinic or provider the patient is going through, then we have to make sure that there's an available slot.”
Weber continues by explaining that provider capacity plays a role, and some clinics are oversubscribed, so they try to find an appointment as early as possible, sometimes asking their provider to overbook if it is an urgent situation. Then, the provider has to sometimes order additional studies which can cause scheduling complexity. There also may be multiple providers that need to see the patient. “All of that can create more days to get to the patient and that’s an untreated patient,” he said.
Hagland then inquired about how Weber’s team uses data to analyze the situation and then apply it. Weber said, “We’re in an academic institution and all of our positions/providers have different responsibilities and roles—education, research and clinical care being the big three—‘a three-legged stool.’ So every year we have a declaration of clinical output, for me as chair, it is about 60 percent clinical and 40 percent other paths. If you take that 60 percent clinical, that translates into time in the clinic, time in the OR [operating room], and also accounting for the new patient divide. Say I was scheduled to 250 new patients a year, I have to make sure I give my clinic 44 weeks a year and we’re disciplined about that.”
Weber added “We have an access monitoring group and the purpose of that [group] is to monitor our key performance indicators or metrics. We track how many new patient slots we have for demand institution wide. And it's not just for the cancer center, it's all of our area locations as well. And then we look at the cycle time for financial queries—the cycle time from when the access team refers the patient to a provider and get approval. So we're looking at all those process metrics and we're looking at where they're headed. We want to give an appointment on that first or second call from a patient. We also meet with our service line leaders, periodically. We have a cadence meeting with them about once a month to review all the data. So it's transparent, one service line can see how the other service line is performing. And that that in and of itself creates healthy competition.”
On a scale of one to 10 regarding how difficult it is to work out these complexities, Weber joked that it was “about a 10 and a half.” “This is about culture change,” he stated. “And there's nothing more difficult than changing a culture within an institution. It's not that our providers don't want to see patients, but they have other responsibilities. If you're a surgeon you’re in the OR three nights a week so you’re not planning on seeing new patients. If you're clinical trials, that takes a lot of time—a lot of meetings, reviewing data, making sure you're in compliance. We have all these different things pulling at us. But then at the end of the day, we have to convince providers that our job is to see in cancer patients as quickly as possible. And that's where the cultural change comes in. Let's drop impediments to access, let's drop the unreasonable acceptance criteria. But that's where the culture part of this is. And that is a big challenge.”
And for the single biggest challenge Weber faces and how his institution recovers from it, he said, “Just the complexity. We’re highly subspecialized, take for instance our GI clinic. They probably have 16 different subspecialties within GI and there's a capacity for each of those. And sometimes, like for pancreas, we're always starting from scratch. So getting those patients can be really difficult. I think one area that we need to work on is our access team. They're dedicated folks, but we give them algorithms, one of them is 1,000 lines long, it’s not working. They have to go through the algorithm to see if the patient they're going to put them in the right way. We need to insert medical decision making within that process, removing that from the access specialists’ responsibilities. They're good at processes like insurance, getting records, and scheduling and consults that we request for that person, but they’re not great at decision making. We’re looking at a nurse navigator as part of the triage option to take that information and understand the algorithm much better than a layperson. Yet, it’s expensive. But I think that’s going to be one of the keys to repair access.”
