As patients have been obligated to assume more responsibility for their healthcare costs, decisions about where to receive care are frequently made based on out-of-pocket fees and their satisfaction with the provider, both physician and hospital.
The following content is sponsored by Adreima.
This shift from payer reimbursement to patient reimbursement has major implications for revenue cycle management, forcing it to abandon traditional processes for the adoption of patient-centric practices.
In a roundtable discussion, three healthcare leaders discuss patient advocacy and how it improves the outcome of revenue cycle management. John Bucci is director of patient accounts at Camden, N.J.-based Cooper University Health Care, Scott Williams is associate vice president of Durham, N.C.-based Duke University Health System's Patient Revenue Management Organization, and Mollie Drake is senior director of corporate access management at San Diego-based Scripps Health.
The following discussion was lightly edited for length and clarity.
Question: How has the rise of consumerism in healthcare affected your revenue cycle?
Scott Williams: It's forced us in a good way to try to be more proactively transparent with our patients, more on the financial side than on the clinical side. We try to do a better job of letting the patients know upfront what their portion of the bill is going to be. It's a fair question that patients have long had of providers: Why is it I can go into the grocery store and know what I'm going to pay for, and when I buy a car I know what I'm going to pay for, but when I go to a doctor or a hospital, I find out what I'm going to try to pay for after the fact?
It's certainly more complicated in healthcare simply because of the complexity of the business. For a large healthcare organization, there are 100,000 different combinations of services you might need — some as simple as going to a primary care physician for an office visit, and some as complex as going through treatment for a transplant. With that complexity and variety, it's a lot more difficult for providers to effectively define with any level of accuracy and precision what the cost of that service is going to be and the patient's share.
The need for greater transparency and the entire consumerism in healthcare movement is progressing primarily because payers and employers are gradually moving more responsibility for payment from the insurance side to the patient side. In our marketplace, we've been talking about high-deductible health plans and higher levels of coinsurance over the last five to 10 years, but honestly it's really within the last two years we've seen that accelerate to a greater degree. With a fair amount of frequency we are seeing patients with deductibles of $3,000, $5,000, $8,000, $10,000 or coinsurance amounts that have grown from 10 percent up to 20 percent, 30 percent and 50 percent. And because of those market changes, the patient now is responsible for a lot more of the bill then they used to be. The challenge is for the providers to use the technology that is more available today to try to proactively provide some education and guidance to patients.
At Duke, one strategy we've implemented is pre-visit estimates for our more complex services. We do a pre-visit estimate for the patient in advance by identifying the service that we're gong to provide and then based on the known insurance benefits for that patient, we estimate what the patient's true responsibility is going to be. Based on that information, we call or communicate with the patient ahead of time — partly for educational purposes, but also to collect that patient responsibility at or before the time of service if possible.
Mollie Drake: Patients are becoming more cognizant of their benefits and out-of-pocket costs. We are getting more requests to determine what they will owe in advance of scheduling a procedure. In some cases, this has impacted the patient's decision to go forward with the service.
John Bucci: Consumers are much more well-informed. We see more patients that shop around for price than ever. Coverage [options] have changed. More and more today people are choosing, or their employers are choosing, more catastrophic coverage. So their deductibles and their co-payments are much higher than before. So knowing that they have to put more money out of their pockets, consumers are shopping. They want to know their out-of-pocket cost for procedures, particularly with certain types of preventive care. I think that's one of the big differences that we see. Patients ask a lot of questions in regard to what the out-of-pocket is going to be, so they are much more educated than say 20 years ago.
Q: How has consumerism affected your front-end flow?
SW: It's required us to beef up the front-end staffing of our revenue cycle in terms of quality and quantity. With most provider organizations, some of our lowest-paid employees are the ones that are right there at the front desk checking in patients on the inpatient or outpatient side. So we're moving toward trying to upgrade those positions to make them more knowledgeable instead of just friendly hellos. We're trying to beef up their expertise so they are more conversant to patient's inquiries and benefit coverage. Certainly technological advances, with both the Internet and the use of a variety of patient accounting systems over the last five to 10 years, are something that's happened across the industry. We now have the capability to store and track that information in a much more accurate and comprehensive way and to do that in real time.
MD: With the increase in requests to determine a patient's out of pocket comes an increase in the time spent with each patient.
JB: We use Adreima as our eligibility vendor. Adreima has 27 full-time employees stationed at various points of service at the hospital. We cover the emergency department 24 hours a day with several people during peak hours. We also have eligibility staff at every point of service trying to assist the uninsured or underinsured patient with programs available to them. We spend an extensive amount of time really trying to see how we can help a patient in terms of securing some type of coverage, through either NJ FamilyCare (New Jersey's publicly funded health insurance program), Medicaid expansion, or through charity care and other available programs.
There's a lot of work that goes into that. And that's 27 full-time people just from Adreima, not to mention our folks when someone comes in. When you talk about someone coming in for a scheduled event, it's one thing, but being a Level I trauma center here in Camden, we also get a lot of people who come in through the emergency room, and their coverage is nonexistent — they're uninsured or underinsured — and the challenge is really to try to work with the patient or work with the patient's family and have them provide us the documentation needed to secure these programs like NJ FamilyCare.
Q: How have things changed the way you design your customer service?
SW: Certainly at Duke, and across the industry, there's a lot more focus across our entire organization in being more patient-centric rather than provider-centric. This is driven by the competition in the industry and the greater amount of information readily available to patients via the Internet. The reality is most healthcare systems, and Duke is certainly in that category, are trying to look at virtually everything we do from the patient's perspective — both from a clinical and an administrative perspective. We have hired a number of people within our organization at a variety of levels to look at our processes holistically from a patient-centric perspective and redesign administrative and clinical operations to try to maximize the patient's experience.
MD: We are investing in tools to help streamline the research needed to determine the patient's share of a given service. With the increase in high-deductible plans, this tool will let us have a more meaningful financial discussion with most patients before their service, and not just those who inquire.
JB: I equate it to the retail world: If we're not providing a high level of customer service from the minute that they walk in the door, patients will or could look to go somewhere else. There are extraordinary things that we go through, such as really sitting with the patient and their family and educating them on the marketplace. Someone will sit down and not only explain what it's going to cost them, what their insurance is like, but we also have these kiosks set up at various points of the hospital so if the patient wants to look for coverage through the marketplace, we have people who will sit with them and explain what all those coverage options mean because it's confusing to people. If you have someone who is going to be treated for cancer, they try to explain how that coverage would line up with their condition. They try to explain what coverages will benefit them. We don't tell them what to buy. We ultimately let them make that decision. But we try to explain it to them so they know the type of coverage based on the treatment they're going to get.
I think the experience starts before the patient walks through the door. I think it starts when the patient calls and asks questions or wants to schedule an appointment through the billing process, which has to be a good one too. If they receive something in the mail and they have a question, they should be able to pick up the phone, ask a question and somebody should answer it in a way they understand.
Q: Are you using more portals? Self-pay?
SW: We've had an online portal for patients for some of their clinical and revenue cycle interactions with Duke for almost 10 years now. We upgraded our clinical and revenue cycle systems to Epic about two years ago. Part of that was to enhance our electronic medical record in support of meaningful use requirements, but part of it was to enhance the capabilities and integration of our clinical systems and patient accounting system. Epic's web portal functionality, MyChart, is significantly greater than what we had previously in terms of allowing patients to do more online such that patients can now schedule and cancel an appointment, see test results, view and pay a bill, request a prescription renewal, and send a question to their provider. We have 400,000 patients that have an online portal account with us, with varying degrees of frequency of usage based on their healthcare situation. Again, it's not a solution for everybody because some patients are more Internet savvy or desirous than others, but a surprising number of patients are taking advantage of it and actually prefer using that technology to complement their entire experience.
JB: As far as self-pay patients, in many cases we can get them set up in some programs like NJ FamilyCare, or have the complete presumptive eligibility application. I think the trend we have seen since Medicaid expansion is a decline in the self-pay population. Now we're able to help them and get them into a program that will not only allow them coverage, but coverage beyond the hospital. With these programs, we're not only able to get them NJ FamilyCare because their income is a certain level, but with that they're able to see primary care physicians. They're able to get the preventive care and medication they need, so that patient won't need to come to the emergency room. The end result is a very big win, in my opinion, for the patient because those programs are out there, and the key component really is being able to educate the patient that we're there to help.
Q: What has your facility done in terms of patient advocacy?
SW: We are working not just within the Duke family, but in conjunction with our community providers and advocacy groups within our primary service area, to fulfill our obligation to provide healthcare to patients whether they can or can't afford to pay. We have a financial assistance policy to identify and qualify patients for charity care if they can't afford to pay for necessary services. Certainly with the rise of the healthcare exchanges and the government-subsidized premiums for coverage there, we've gone out of our way to educate patients on the availability of those programs.
We also have a 20-person group within Duke that focuses on helping patients qualify for Medicaid eligibility. Some of these government programs are not the easiest to figure out, so this group works with patients already in-house or that come to Duke needing services. They will even go out to people's houses to gather information to help them qualify for benefits and programs that make it easier for them to work their way through the healthcare experience at Duke or other providers. Those are some of the things that we're trying to do to reach out and realize that patients come in all shapes, sizes and financial conditions obviously. I think those types of efforts will gradually continue and evolve as the healthcare insurance market continues to mature.
JB: We have a patient relations department for instances where the patient has a concern — whether it's a concern with their billing or with the quality of care they received. The department handles things that are mundane to things that are really very important. And then they have to work it through. We have a whole system where once a patient talks about a dissatisfier, they have to provide resolution to the patient. And if they have to bring a clinician in because it is something that is medically based, then they do that. So there's a tremendous effort to ensure that when the patient leaves they're happy with the Cooper experience. Again, I use the retail illustration. If they're happy they will return. You're trying to provide a high level of care. You're trying to make sure you treat the patient with dignity and respect. And if you do those things, they're going to want to return to us. And if you don't do those things, well, there are plenty of other hospitals in the area they can go to — and they would.
MD: Scripps has a dedicated team of highly trained staff to assist patients with applications for County and State programs, including Medi-Cal and Covered California. They help the patient throughout the process and the gathering of various required documents. We also contract with an external agency who will handle appeals when cases are denied.