January 2014 Visit Volume

[Back from vacation!]

Starting in mid-January, we began to hear rumblings and then outright panic from our clients about their patient volume diving steeply.  Although most practices recognized the impact of the crazy weather and practice/school closings, the most common explanation I heard was that “high deductible health plans” are to blame for the big drop.  I know a few practices who laid off staff and even some who let clinicians go!

I suggest looking more closely at the data.

The first thing we decided to do here is to verify the change in volume.  Was January 2014 slower than January 2013 for pediatricians?  And if so, how?

Realize that this is a tricky thing to measure across many practices.  It’s one thing to look at just your own practice – as you should – but more of a challenge when looking at a national data sample.There are many reasonable variables that affect a practice’s volume.  How many work days are in a given month?  Were clinicians on vacation?  Has the practice gained or lost clinicians?  Has the practice added or subtracted clinical hours, like late nights or weekends?  We gathered the data for all PCC clients and narrowed our focus to those practices who were open full-time from January 2011 through January 2014 and converted their monthly visit totals to a daily average, normalizing for the number of weekdays in each month.  That delivered us this data (click for a bigger view)

Jan 2014 Visit Data

There are a couple of things I want you to see here.

  • Pediatric visit volume is cyclical with a sick season that hits between October and February.  Note the four peaks of this time range: Feb 2011, November 2011, October 2012 (and again in Jan 2013), and October 2013.  Once you account for the fact that we can’t control when the sick season happens, you realize that comparing January 2014 (post-peak) to January 2013 (peak) doesn’t make a lot of sense from a practice productivity standpoint.  Remember that your peaks and valleys may come at different times depending on your location.  For many practices coming off of the high Oct/Nov, January just felt bad more than it indicated a real problem.
  • Note the red trend line (I hope you can’t miss it).  There has been a clear downward trend in visit volume for PCC clients for some time.  Adjusting for clinical blips like H1N1, PCC’s customer visit volume has slowed every year as far back as we have tracked it (over 10 years).  There are a couple of obvious reasons for this but the big one is right in front of you: increased focus on preventive care.  The PCC client Sick:Well visit has dropped from 2.7:1 to 1.8:1 – which means fewer visits but a much higher Revenue/Visit (essentially doubling in that time).

What does the chart not tell us?  A few things.  One special variable to is the weather.  With 22 weekdays in Jan 2014, all it takes is one missing day to create a ~5% drop.  Two days get you nearly 10%.  And although some practices never closed at all, many definitely suffered enough from bad weather to slow volume and not eliminate it.  And let’s not forget that every time school closes, the viruses die off, too.

I have more data, quite a bit more, but let’s bite off this chunk and see what people think.  Input welcomed, please.

19 replies
  1. Jesse Hackell MD
    Jesse Hackell MD says:

    Great data, Chip! Thanks for providing it. I suppose using monthly comparisons or yearly data will help smoothe out the peaks and valleys.

    One problem with the well:sick ratio is that the effect of a drop can be positive if caused by an increase in well visits, but negative if caused by a fall off in sick visits, if well visits remain constant (which is suggested by the trend line). Would it not help to provide a measure of average number of well visits in conjunction with the ratio?

    Reply
  2. Lynn Cramer
    Lynn Cramer says:

    I agree that preventive care lowers frequency of acute care visits as patients/families are more prepared to provide care for many illnesses at home
    Technology has also made it possible for home care to be provided in more complicated illnesses
    We can increase insulin pump rates for diabetics and monitor corresponding BS
    All asthmatics have controller and acte med treatment plans
    We have done an excellent job of educating on home care for viral illnesses
    Then of course childhood vaccines added,vaccination rates have improved for flu
    All good things
    Now if we only had a way to measure preventive visits for chronic disease the 9921x to see how it impacts the acute 9921x visits
    The scale above cannot tell me how many of these visits were asthma preventive control visits, ADD control, etc as compared to acute asthma illness
    So of course the “acute” visits are probably even lower and have been replaced with chronic condition preventive visits that are coded with the same CPT right?

    Reply
  3. Gino Figlio
    Gino Figlio says:

    I think there data would be more clear if your grouped your clients by zip code or region. The weather has a direct influence and sick season probably starts at different times in the east versus west coast. My personal data for the last 5 years shows a clear peak around February every year, and 2014 has been slower by close to 10%.

    Reply
    • Chip Hart
      Chip Hart says:

      I have the regional data and I am sorting it out. I had the same premise you do, but it’s not showing up that way (some of our clients in the SE, like Arizona and New Mexico, are among the hardest hit in January). I need to dig a little deeper and make some calls!

      Reply
  4. Irwin Berkowitz
    Irwin Berkowitz says:

    Although I agree with you regarding the regular peaks and valleys of our patient visits as well as the effects of the especially nasty winter on our volume, I can’t totally agree with your premise about the downward trend in patient visits.
    I am sure there is a minor effect of the excellent preventive care we provide. I think that the increasing copays as well as the high deductible insurance results in a more judicious use of medical services by both parents and patients.

    Reply
    • Chip Hart
      Chip Hart says:

      Well, let me ask you Dr. Berkowitz: why is is that I hear about the HDHP effect mostly from practices in affluent areas?

      Copays have been in place since the 90s and I have tracked their impact. It’s there, and it kicks in once you get over $20. But it’s not as though you have huge groups of patients who went from $0 to $100 copays in January. Have you also noted significant HDHP growth? They have also been around for some time.

      Reply
  5. Adam
    Adam says:

    Thanks Chip, very insightful. I think it would be helpful to graph well and sick visit data by year (which we did for our practice), with Jan-Dec on the x axis, but one line for each year. I emailed you a similar graph for our practice.

    Reply
  6. George Rogu
    George Rogu says:

    I think that we need to rethink our day. he old days of saving appointments for the sick, and the oh my god I am gonna be so busy are behind us. We need to concentrate on Preventative care

    Doc Rogu

    Reply
  7. Mike Chamberlin
    Mike Chamberlin says:

    It looks like there were two peaks (bimodal) in 2011 and 2012, one in the fall and one in the winter. This year, it looks like we will not have that winter peak. With a greater push for flu vaccination, we have increased our fall visits over the last several years which has created an October peak. Chip, do you think the October peak is illness or increased well visits due to better efforts to vaccinate against the Flu?

    Reply
    • Chip Hart
      Chip Hart says:

      I was wondering the same thing but feel like we’d need the next 3-6m of visit data to be sure. We have had a few reports (at PCC and on SOAPM) about February picking up considerably. Clearly, though, if there is an external variable that affects your peak volume time, like weather, you could skip over one of those bumps.

      Great question about the October peak – flu shots or illness? I’m going to guess that it’s some of both. I’d have to go back farther, but I’m going to look at the regional and visit-type breakdown first. Let’s see if that doesn’t illuminate for us! Let me know if it doesn’t.

      Reply
        • Mike Chamberlin
          Mike Chamberlin says:

          My mistake. I thought the graph represented all visits and not just ill visits. We do a lot more well child visits in the fall (Sept-Nov) than we used to because of our increased focus on flu vaccines. So, our total visits in the fall has increased over the last several years due to this.

          Reply
          • Chip Hart
            Chip Hart says:

            I’ll have some visit-type data for you shortly!

            I think the well-visit-plus-flu-shot volume is mitigated slightly by the large volume of flu-shot-only visits our clients tend to do. We’ll see though!

Trackbacks & Pingbacks

  1. […] Last week, I posted some data about national visit volume that I hope made clear that the perceived dip in the January 2014 visit volume was largely cyclical and weather related.  Sure, there are some practices whose variance isn’t explained so easily.  For example, one of the comments I received reflected my own thoughts: […]

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