---
name: administrative-denominator-reduction
description: Use this skill when a practice wants to cut what a Medicare between-visit program costs to run without cutting care, decide what to automate first, find out whether it really needs another coordinator or nurse, or stop a monitoring or alert stream from turning into another inbox. It maps the nine-component Care-Delivery Operating System, itemizes the Administrative Tax, runs the two-week admin-minutes study to measure the Administrative Denominator (admin minutes per patient-month), sorts every task with the Machines Remember; Humans Decide three-way sort, sizes caseload from minutes, applies the Signal-to-Attention test to data streams, and names the first three automation targets and where the freed minutes go. Triggers on requests like "measure our admin minutes," "run the time study," "what should software do in our CCM program," "should we hire another coordinator," "map our nine components," "what lives in Janelle's head," "our nurses are drowning in RPM alerts," "is this AI prioritization safe," or "what do we automate first."
---

# Administrative Denominator Reduction
This skill is Labor as Code™ for the cost-of-delivery method in
*Getting Paid to Do the Right Thing*. Labor as
Code is a skill that encapsulates a person's knowledge, judgment, taste,
and skill in durable, inspectable, versioned form. The know-how is
the book's economic engine: the payer fixes the payment per
patient-month, the practice controls the admin minutes it spends earning
it, and software changes the denominator when it takes over the
remembering, counting, and checking while people keep the conversations
and decisions.

The method spans five chapters. "A Billing Code Doesn’t Tell You How to Run the Care" names the
Care-Delivery Operating System and its nine components, and defines the
Administrative Tax. "Spreadsheets Hide the Admin Minutes That Make Programs Lose Money" defines the
Administrative Denominator, admin minutes per patient-month, and the
two-week study that measures it (Tables 6.1–6.3). "Software Should Track the Work and People Should Make the Decisions" gives the three-way sort and Riverbend's first three
automations. "Stop Building Another Inbox" gives the Signal-to-Attention
test and the two monitoring numbers. "The Care Team Is an Operating
Specification" gives the caseload formula. Read them for the argument
and the Riverbend, Lakeshore, and Northfield cases. This skill applies
the same steps to the user's own program and never reuses the cases'
minutes as the user's.

**The skill measures; it doesn't estimate.** Estimates of admin work
come in low, because the minutes nobody planned for are the minutes
nobody remembers spending. At Riverbend, a careful nurse's estimate of
12 admin minutes per patient-month measured 20. The skill can help
itemize an estimate, and it labels that as an estimate until a two-week
log replaces it.

**The skill never moves a care minute to make a number look better.**
The goal is to turn admin minutes into care minutes. Any scenario,
caseload, or projection that lowers care minutes is wrong, and the skill
throws it out.

**The skill takes totals, not logs.** Study logs carry study IDs and
times. The user totals minutes by task code and role; only the totals
come into the session. No identifiable patient data, and no pasting of
records into a tool without a business associate agreement.

## Before running

1. **Name one program.** The study, the sort, and the caseload all run
   per program.
2. **Ask what prompted this.** A hiring request, a vendor demo, a
   program losing money, a nurse staying late, an alert load. Write it
   down; Step 7 answers it.
3. **Ask who touches the program.** Every role: nurses, medical
   assistants, front desk handling consent, physicians on escalations,
   the administrator reconciling remittances. Leave out an outside
   billing company's staff; its fee goes into Practice Math separately.
4. **Ask for the enrolled count** for the period. Every per-patient
   number here divides by enrolled patients, never by served or billed.

## Step 1: Map the nine components

For each component of the Care-Delivery Operating System, ask where it
lives on an ordinary Tuesday: software, a spreadsheet, a person's head
(name the role), or nowhere. Not where it should live, and not where
the EHR vendor says it could.

1. Eligibility logic
2. Enrollment and consent
3. Care plans
4. Work queues
5. Escalation pathways
6. Documentation
7. Billing validation (the pre-claim check)
8. Audit evidence
9. Quality and outcome review

For every component in a head or nowhere, say what would break in a
month when that person is out, how anyone would notice, and rank them
by risk. Don't accept "in the EHR" as safe on its own; a care plan
nobody updates lives in the EHR and still doesn't work. Write next to
each component the one person who would notice if it stopped working.
A component with no name is a failure waiting for a date.

Software is the right home for anything that is mostly memory:
eligibility, queues, time capture, pre-claim checks, audit trails.
People are the right home for judgment: the consent conversation, the
escalation decision, whether a patient is better.

## Step 2: Itemize the Administrative Tax

Ask the person who does most of the program's work to list every task
a patient would not recognize as care, with rough minutes per enrolled
patient-month (or per episode, for an event program such as
transitional care). Don't argue with the estimates yet. Total them into
monthly hours.

Keep the Administrative Tax distinct from the Workflow Tax in
*Doing the Right Thing Is Not a Business Model*. The Workflow Tax is
unbilled labor a product imposes. The Administrative Tax is created by
the program itself and exists before any software arrives. A product
can lower one and add the other; count both when judging software.

For an event program, check the first task hardest. For transitional
care, "finding out the patient was discharged" decides whether any of
the rest happens, and a discharge the practice never learns about never
shows up as a denial or as admin minutes.

## Step 3: Run the two-week admin-minutes study

Give the user the method exactly as the book states it:

1. Pick one program and one two-week period without holidays.
2. List every person who touches the program; give each a log sheet.
3. Give every enrolled patient a study ID, a number and never a name.
   Keep the key apart from the logs.
4. Print the task codes at the top of every sheet.
5. When a person starts a program task, they write the start time, the
   study ID, and the task code.
6. When they finish, they write the minutes, rounded to the nearest
   minute. A voicemail is one line, even at one minute.
7. An interruption ends the line; start a new line on return.
8. At the end of each day, each person spends five minutes filling gaps.
9. At the end, total minutes by task code and by care or admin.
10. Multiply the two-week totals by 2.17 to get a month, and divide by
    the number of enrolled patients.

The task codes:

| Code | Type | Task |
| --- | --- | --- |
| C1 | Care | Talking with the patient or caregiver |
| C2 | Care | Medication reconciliation |
| C3 | Care | Coordinating on the patient's behalf (refills, referrals, appointments the patient needs) |
| C4 | Care | Clinical decisions and escalations |
| A1 | Admin | Eligibility, enrollment, and to-call lists, including working out whom to call |
| A2 | Admin | Calls and messages that reach nobody |
| A3 | Admin | Chasing records and other offices for information |
| A4 | Admin | Writing the note and logging minutes |
| A5 | Admin | Checking the record before billing, and fixing what the check finds |
| A6 | Admin | Consent and care-plan paperwork |

The care-or-admin test is one question: if this minute disappeared,
would the patient notice? That puts writing the note on the admin side:
necessary, and the first minute worth shrinking. Whether a minute counts
toward a billing threshold is a separate compliance question for the
compliance adviser.

When the totals come back, compute admin and care minutes per enrolled
patient-month and show the arithmetic so the user can redo it by hand.
Rank the admin codes by monthly minutes. Compare each code with the
Step 2 estimate, line by line. Report two more things if the data
allows: the admin minutes absorbed by enrolled patients never reached,
and which person pays most of the tax.

If the study hasn't been run, stop here for any hiring or buying
recommendation and say so: the correct next step is the study.

## Step 4: Sort every task into three bins

List the program's tasks with their measured minutes and a care or
admin label. Put each task in one bin:

- **Machine does it:** remember, count, schedule, route, match, check
  completeness, flag missing data, stop an incomplete claim.
- **Machine assists:** summarize, draft, classify, suggest, with a
  person reading, correcting, and owning every output before it reaches
  a patient, a chart, or a claim.
- **Human decides:** diagnosis, treatment changes, whether a pattern
  matters, the consent conversation, anything a license or judgment is
  for, and every escalation.

Settle each task with the book's three questions, in order:

1. Is the task remembering, counting, or checking against a rule? Then
   a machine should do it.
2. If the machine got it wrong, would a person catch the error before
   it reached a patient, a chart, or a claim? Then it can be
   machine-assisted.
3. Does the task need a license, a judgment about this patient, or a
   conversation the patient has to trust? Then a human decides. A yes
   here wins over the first two answers.

Flag every task whose bin depends on how the software is designed.
The test is what happens to the patients the software doesn't show
you. A list of everyone who owes the program something, sorted by how
overdue, is scheduling. A risk score that quietly drops the bottom of
the panel is a clinical judgment nobody licensed made. Any clinical
judgment in "machine does it" is misplaced, and any care minute moved
into a machine bin is wrong.

Then project: machine-does tasks fall to the minutes a person spends on
exceptions, machine-assists tasks fall to review time, care minutes
stay where they are. Label the result "projected." A sort ranks
targets; it doesn't predict what real software does with real patients.
Riverbend projected 10 admin minutes and measured 14 after its changes.

Name both automation failures when the user's sort shows them.
Irresponsible automation is a human-decides task in a machine bin.
Under-automation is a machine-does task in a human bin, such as a nurse
counting minutes or re-keying readings. The fix for both is the sort.

## Step 5: Apply the Signal-to-Attention test to any data stream

Skip this step if the program has no device readings, portal messages,
or AI alerts reaching clinicians. Otherwise, ask one question of each
item type: does this item need a human decision today?

- If yes, it goes to the right person with context and a deadline.
- If no, the machine handles it (a reminder, a receipt), summarizes it
  (a month of in-range readings becomes one line), or holds it (a single
  high reading waits for the next one).

Rules that don't bend:

- An item reporting new symptoms always goes to a person, whatever its
  action rate.
- Missing data is not a clinical decision. It goes to a coordinator,
  never to a physician.
- Clinicians write every threshold and sign it. The skill proposes the
  shape of a rule and leaves every clinical number blank. Replace any
  population default with a blank for the patient's personal range.
- Every tier has an owner and a deadline. An escalation with no deadline
  is a message.
- Nothing reaches a physician as raw device data; escalations come
  through a nurse with a summary and a specific question.

Compute the two numbers from the user's counts: **alerts per
clinician-hour** (items reaching a nurse or physician ÷ hours they spent
on the program) and **percent of alerts that led to an action** (a call
that changed something, a treatment change, an appointment, or an
escalation ÷ all items reaching a person). A click on "reviewed" is not
an action. The fix for a low action rate is a better trigger or a
better cohort, never faster clearing. If a clinician can't name a
reading that would change what they do for a patient, ask whether that
patient belongs in monitoring.

## Step 6: Size the caseload from minutes

Only after the study:

```
caseload per coordinator = monthly work minutes ÷ (care minutes + admin minutes)
```

Ask for the coordinator's real monthly work hours after time off,
meetings, and training. If the user doesn't know, the book reports
about 130 hours (7,800 minutes) in most practices the author has seen;
label that as the book's observation, not the user's number. Recompute
at three lower admin-minute values and show how many coordinators a
target enrollment needs at each. Care minutes stay fixed. A caseload
that works only by cutting care means the program doesn't work at that
staffing level.

Check physician minutes the same way if the user has them. If the
escalation rate is well above what the user's own clinicians expect
(the book's illustrative figure is about 8 percent of enrolled patients
a month), check the escalation rule before checking the physicians;
coordinators with no written rule escalate everything.

## Step 7: Conclude with targets, destinations, and the hiring answer

Close with a short recommendation, not a table dump:

- **The three largest machine-does or machine-assists admin tasks,** as
  the first automation targets, in order, with measured minutes. For a
  solo or small practice the book's first target is the worklist,
  because memory fails first. For a small group it's the same time
  capture and pre-claim check at every site, so sites count the same
  way. For a large organization, sort the tasks before automating a
  central department's workflow; automating an expensive structure makes
  it a slightly cheaper expensive structure.
- **What to try before buying anything.** Check whether the EHR or
  existing contract already includes an unconfigured module. Automate
  only what someone has watched a person do by hand. Test any tool
  against a month the practice already reconciled by hand.
- **What not to automate yet,** with the reason: anything that hides
  patients from the list, outreach drafts nobody has read, ambient notes
  before the practice has checked drafts against real calls.
- **Where the freed minutes go.** A saved minute has no cash value
  until someone decides where it goes. Ask the partners to decide in
  advance (for example, offering the program to eligible patients never
  asked). If the minutes are simply absorbed, say plainly that the
  program's economics won't change.
- **The hiring answer.** At the measured admin minutes, does the
  caseload formula support a hire? The book's rule: measure admin
  minutes before hiring anyone, fix the most repeated admin tasks, then
  rerun the formula and hire against that number. A new person added to
  a program at twenty admin minutes per patient-month mostly buys more
  spreadsheet.

Where the choice is genuinely open (two targets of similar size, one
software and one process; or a design-dependent task where the vendor's
answer isn't known), lay out both with their reasoning and what would
decide between them. Where no study has
been run, say the evidence can't support a hiring or buying decision
and name the two-week study as the step that would.

## Checks before calling the work done

- **Every per-patient number divides by enrolled patients,** billed or
  not.
- **Care minutes are identical in every scenario and caseload.**
- **Estimates and measurements are labeled as such,** and projections
  say "projected."
- **No clinical number was set by the skill.** Every threshold is a
  blank for a clinician.
- **Every component and every tier has a named role.**
- **The conclusion names three targets, where freed minutes go, and a
  hiring answer or the measurement it waits on.**

## What this skill does not do

It doesn't recommend a vendor or product. It doesn't set clinical
thresholds, decide escalations, or decide which patients can wait. It
doesn't decide whether a minute counts toward a billing threshold; that
is a compliance question. It doesn't borrow Riverbend's 20, 14, or 10
admin minutes, or the book's $0.75 a minute, as the user's numbers. And
it doesn't call a program efficient because care minutes fell. When the
minutes haven't been measured, the correct output is "run the two-week
study first," not an automation plan built on a guess.