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Cost Implications of Human and Automated Follow-up in Ambulatory Care
Eta S. Berner, EdD; Jeffrey H. Burkhardt, PhD; Anantachai Panjamapirom, PhD; and Midge N. Ray, MSN, RN
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Cost Implications of Human and Automated Follow-up in Ambulatory Care

Eta S. Berner, EdD; Jeffrey H. Burkhardt, PhD; Anantachai Panjamapirom, PhD; and Midge N. Ray, MSN, RN
This study examined the costs of nurse-initiated or automated follow-up processes for patients seen in ambulatory care settings


To compare the costs of human and automated follow-up processes in ambulatory care.

Study Design
Analysis of costs of nurse-initiated and interactive voice response (IVR) system follow-up interventions.

Using national cost data and data on follow-up processes and outcomes from a previous study, we examined the costs to the healthcare system and providers of developing a follow-up process using nurse-initiated telephone calls compared with calls made by an IVR.

Whether using nurse-initiated telephone calls or IVR calls, costs over the first 2 years of follow-up for a practice assumed to have 4800 acute care patient visits per year are approximately the same. After 2 years, IVR follow-up is approximately $9000 per year less expensive than nurse follow-up. In addition, overall cost savings are greater with IVR.

Follow-up of ambulatory care patients is a way to assess risks of future problems and associated costs and to improve quality of care. An automated follow-up process using IVR is more efficient than one based on nurse-initiated follow-up calls.

Am J Manag Care. 2014;20(11 Spec No. 17):SP531-SP540

Take-Away Points

Follow-up interventions with patients can potentially produce cost savings for the healthcare industry, and for providers specifically, by appropriately managing patients with varying degrees of risk.

  • Follow-up processes can identify patients who are unimproved after an initial physician visit
  • An automated follow-up process using an interactive voice response (IVR) system is less costly, with greater cost savings, after the first 2 years than processes using nurses to follow up with patients.
  • Because most patients will not need further treatment after their initial visit, the IVRS is more efficient than nurses at identifying the high-risk patients who do need additional medical attention.

Driven by the value-based and financial implications of healthcare reform, providers have begun to transform their delivery structure, emphasizing the shift from inpatient to ambulatory settings and manag- ing patients in an appropriate setting along the care continuum. Reflecting such trends, CMS has reported more than half of Medicare Accountable Care Organizations (ACOs) are led by office-based physicians, outnumbering hospital-led ACOs.1

One critical comn health management, which involves patient monitoring and proper follow-up care by primary care providers.2,3 While the true performance of an ACO depends on its ability to simultaneously manage patients with varying degrees of risks, the most critical group needing urgent attention is high-risk patients. The high-risk patients are the smallest group within the overall patient population, but they represent the highest healthcare spending.4-6 Therefore, providers are likely to produce cost savings if they can reduce or prevent multiple visits by, or hospital readmissions of, high-risk patients. Thus, in addition to performing risk profiling to proactively segment the patient population, providers should also identify the risks associated with a given acute episode via active monitoring and proper follow-up.

While important, such practices are in fact rare in ambulatory settings.7 Little data exist on either the cost implications of doing such follow-up or on the cost savings that might be anticipated by closer or more complete monitoring of ambulatory patients.

We developed a mechanism for automated follow-up of ambulatory patients seen for acute illnesses.8 The automation mechanism studied was an interactive voice response (IVR) system that provides reports to providers through their electronic medical record. IVR has been studied for econom- ic and healthcare utilization impact, reminders to patients for screening tests, and for pharmacologic monitoring.9-11

Berner et al evaluated patient-reported outcomes of improvement, as well as patient interaction with the health system.12 The present study uses data from the Berner et al study12 to examine the cost implications of automated, compared with human, follow-up in ambulatory care.


Data Sources

The development of the IVR system and the study of outcomes have been described in detail elsewhere.8,12 The study, approved by the Institutional Review Board at the University of Alabama at Birmingham (UAB), was conducted over 3 phases with 3 cohorts of patients in each of 3 ambulatory care sites that led up to full automation of the follow-up and feedback process. One site was the “sick call” clinic for acute illnesses in human immunodeficiency (HIV) patients who were being followed in the UAB HIV clinic setting. The second site was a family medicine clinic, affiliated with UAB, but located in a different city. The third site was a cerebral palsy clinic that treated a variety of disabled patients.

In Phase 1, patients were contacted by a study staff member 3 weeks after a primary care visit for an acute problem and asked about symptom improvement (improved, or not improved [same or not improved/worse]), medication compliance, and interaction with the health system prior to the follow-up call (called clinic, or made an appointment with their own physician, or saw some- one else [another physician, emergency department, hospital]). This was considered to be baseline data with no intervention.

In Phase 2, with a new cohort of patients, the same questions were asked by a staff member in a phone call 1 week after the visit. In Phase 3, with a third cohort of patients, the questions were asked 1 week after the visit via IVR. Only the first 2 sites participated in Phase 3. In all cases, patients who were unimproved were transferred via telephone to their clinic, where usual care processes were employed.

For the present study, we used the data on patient-reported symptom improvement and interaction with the health system from the Berner et al study.12 We also used data from that research on the average personnel time necessary to pre- pare for and make the phone calls, which was not reported previously. We obtained the average personnel costs for physician office–based nurses from the Bureau of Labor Statistics.13 The 2012 healthcare costs for established and new patient visits were obtained from CMS.14 We chose the Level 3 Evaluation & Management (E&M) code for the visits, to represent an average cost. These data are shown in Table 1.


The analyses for this study were based on the following assumptions:

  1. An attempt will be made to contact all acute care patients for follow-up.
  2. A nurse would be the most likely healthcare staff member to make the follow-up call in the human follow-up situation.
  3. All IVR system setup costs will be paid in Year 1.
  4. Patients who are unimproved/no change at 1 week (in the original study these were patients who were routed to the clinic) would discuss the situation further with a nurse. Since 1 week is still early in the healing process, the discussion with the nurse would be the most likely end point for these patients.
  6. Patients who report they are unimproved/worse at 1 week would discuss the problem with the nurse and would also schedule another appointment with their primary care physician.
  7. The populations reached (ie, patients who answer the phone) or not reached (patients who do not answer the phone) are not different in significant ways. The assumptions for this analysis are based on a primary care practice that sees an average of 100 acute care patients per week for 48 weeks.
This analysis is performed from the perspective of the healthcare system, showing potential costs to the system rather than to individuals. Analyses included comparisons of costs of IVR with human calls, costs of interaction with the health system if early (eg, 1 week) follow-up was initiated compared with no follow-up, and potential cost savings with early follow-up (human and IVR). Because the IVR system setup costs are much higher than maintenance costs, the time horizon includes both the first year (when setup costs are incurred) and the second year (when only maintenance costs are incurred). We also include a cumulative 5-year cost estimate.

Calculation of Cost Savings From Follow-up

The cost savings from follow-up is represented by the difference between the costs that are potentially preven- ted if early follow-up is done (potentially preventable costs) and the costs of conducting early follow-up (1 week post visit), by either a nurse or an IVR system.

Calculation of potentially preventable costs. Potentially preventable costs are those costs that could potentially be affected by the follow-up process. These costs include the costs of interaction with the health system (interaction costs) for patients who have not improved or who have gotten worse and who eventually sought care on their own, when their conditions had progressed to a more seri- ous state. It is assumed that addressing the problems early by means of the follow-up process, even if this leads to interaction costs, could prevent higher costs later. The costs are referred to as potentially preventable because there is no guarantee that the follow-up and early intervention would prevent them.

There are some interaction costs that the follow-up process cannot prevent. These unavoidable costs include: 1) interaction costs of patients who are not able to be reached for follow-up, and 2) interaction costs of patients who complete the follow-up phone call, but who have al- ready initiated the interaction with the health system prior to receiving the follow-up call. If a patient incurs costs prior to receiving the follow-up call, the costs are consid- ered unavoidable since they cannot be prevented by the follow-up process, although other costs subsequent to the follow-up phone call may be prevented. Those who are reached but who do not complete the call are assumed to be improved and to not have additional interaction costs.

Potentially preventable costs are calculated by subtracting the unavoidable costs from the total interaction costs without follow-up.

There are additional interaction costs resulting from the follow-up activities that are necessary to address the needs of those patients found to be unimproved. These costs are included in the costs of follow-up (see below).

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