One way to spot a flash point is to notice when people are using different words to describe the same concept. Throughput is one example of this.
On one side of the table, you have those who grasp that if a provider organization is concerned about patient outcomes, with few exceptions, building relationships with said patients is essential. It’s not entirely clear to anyone anywhere how you manage to build relationships and trust without spending a certain amount of time with patients. These “we need time with patients” people will bring up the Quadruple Aim issues that arise from rigid 7-minute appointments or even 50-minute appointments really.
On the other side of the table, you have those who have built practice fiscal models on the backbone of however-many-minute appointments. They use different terminology for this whole concept, however. They call it throughput. How many patients can a physician manage to squeeze into a day? Some of these folks will tell you that throughput success is “more is more.” In other words, throughput is one of those things that you can never have too much of.
Let me back up for a sec and mention the mission of this show. It is to connect health care leaders together by helping everyone understand each other well enough to communicate effectively, which is rate critical numero uno for any collaboration. You can’t collaborate if parties don’t really grasp what anyone else is actually saying when they communicate their WIIFMs (their “what’s in it for me?”) or their organizational imperatives.
If we consider that the health care industry can only transform when multiple stakeholders collaborate, these little “language discrepancies” actually can have macro implications. In this respect, this throughput example—not in all cases but at a minimum—it’s an exemplar illustration and certainly something to contemplate. Consider people arguing against 7-minute appointments without mentioning the word throughput. They’re probably not going to even reach the headspace of those who just spent the past two decades in meetings to increase throughput. It’s like two ships passing in the night.
You could be sitting there right now pooh-poohing what I’m saying, but I’ve sat in enough meetings where people talk around each other using different terminology, think they’ve agreed on some collaboration or compromise or solution, except nothing happens because everyone got to walk out without addressing the elephant in the room. It sounds something like this:
DOCTOR OR NURSE: We need you to enable patients to have quality time with their doctors and the rest of the care team.
SOMEBODY ELSE: We need to get rid of inefficiencies, which means driving maximum throughput.
ANOTHER PERSON: OK, let’s compromise. Doctors should have quality time while maximizing throughput.
Don’t laugh. I’ve heard “action items” like this often enough, and so have you if you think about it. That’s why I originally started this podcast—because I can also guarantee you if this is the action item, no action will actually take place. The only way this conversation is going to net any change is if people around that table head-on confront that quality time with patients means less throughput. And how much less are we going to agree on and/or how are we going to creatively change the practice model so throughput is an archaic term (ie, asynchronous stuff, etc)?
I say all this to say that this throughput business also leaks into the technology space in ways that we should probably think about. Increasing throughput, after all, is one of the key ways to increase FFS (fee-for-service) revenue. FFS is all about the need for speed. The faster you can smack a billing code on a patient visit, the more patient visits you can pack into a day, the more billing revenue you can rack up. To some extent, throughput is code word for an addiction to FFS. You can always tell a tech vendor who is used to selling in an FFS environment because the second slide of their pitch deck is always one of two things: either how much faster the tool will get patients in and out of a doctor’s line of sight or what the billing code is for the tool (but that’s a whole different topic).
I just described the second slide in an FFS-centric technology vendor deck. The first slide in those “use our AI thingamajig to revolutionize your throughput” decks is always some mission statement about improving patient care. And this is where not everybody using the same language creates immense wiggle room for profit over patients under cover of mismatched terminology.
To add one point of context, when I say throughput here or increasing throughput, nobody is talking about making the front desk more efficient, minimizing faxing things around, or streamlining prior auths or duplications in the workflow (ie, fixing things that are in desperate need of a fix). What we’re talking about in this health care podcast are tools like the one I saw the other day.
This biz dev person of this company was up and about early promoting some AI diagnostic tool. With this tool, so their slide deck promised, a physician could see 50 patients a day. Even for this particular vendor, I guess a full-throated “Hey, let’s burn out all your doctors and make patients wonder if they imagined their doctor visit would happen so fast”—a blunt message like that—presumed a little too much avariciousness on the part of the practice. So, they tempered their message by stating the inarguable fact that there is a physician shortage in rural America and that this tool will help resolve that.
OK … that’s a worthy thing to fix. But, seriously, is the goal to get rural patients an automagical visit with a doctor that, in hindsight, they wonder if they hallucinated it was so fleeting? Or is it to actually help patients get better health? Also inarguably, health care that leads to better health requires less than pedal-to-the-metal throughput. If you think differently and want to change my mind, feel free but show me the study.
I say all this to say that I called up Arshad Rahim, MD, MBA, FACP, a little bit ago to see what he thought of my aforementioned burning premises (aka rants) about throughput; and he kindly agreed to come on the show again. Dr. Rahim is senior medical director of population health at Mount Sinai. He was last on Relentless Health Value on EP219 talking about population health for reals in the real world. Go back and listen to that show after this one if you want to hear more of Dr. Rahim’s sage advice.
One more recommendation: For more insights into the impact of maximum throughput, read the awesome op-ed in MedPage Today by Brian Klepper, PhD, and Jeff Hogan.
You can connect with Dr. Rahim on LinkedIn.
Arshad Rahim, MD, MBA, FACP, is a practicing physician and a health economist at his core. He enjoys a track record of building innovative health care businesses, including Mount Sinai Population Health, Healthgrades, and Sg2. As the vice president, clinical integration and population health, at Mount Sinai Health System, Dr. Rahim is responsible for the 4500-provider Mount Sinai Clinically Integrated Network (CIN) and has built a team-driven practice focusing on key value-based care metrics of utilization, cost, access, and quality. He is also leading a team driving ambulatory care standardization for six key chronic conditions across Mount Sinai Health System. Dr. Rahim has a bachelor’s degree in economics from Duke University, an MD from the University of North Carolina, and an MBA from Emory University. He completed his internal medicine residency at Yale University and Northwestern University and is an actively practicing hospitalist at the Mount Sinai Hospital.
07:37 When does throughput negatively affect patient care?
08:55 Why does diagnostic inaccuracy become a problem with throughput?
09:27 Do population health outcomes decline with less throughput?
10:20 “The way you can also be most financially successful is by taking care of sicker patients.”
10:53 What do patients actually want and need?
11:55 “The emotionality in a health care interaction is always there … [when] you’re focused on throughput, you can definitely lose the healing and calming presence.”
14:18 What do doctors need from their organizations to sustain a high level of care?
15:59 “The actions vary across the spectrum from very supportive to not very supportive at all.”
17:02 “There definitely is a challenge of competitive pay.”