Educational Report

Embracing Consumer Feedback In today's competitive healthcare marketplace, patients' perceptions and opinions hold more weight than they ever have before. As patients start paying more out of pocket for care, they become increasingly selective about where they receive their treatments, looking for just the right facility that consistently meets their needs—both clinical and financial. Going forward, making sure patients are satisfied and loyal will be key to preserving market share and setting the stage for long-term viability. As such, organizations must be well-tuned to their customers' impressions and look beyond traditional patient satisfaction surveys, digging deeper into consumer feedback. With this in mind, this Education Report discusses the strategic impetus for capturing patient perceptions and offers several pathways for putting this crucial information to work.

The Value of the Patient Perspective

Imagine a world in which patients are routinely asked to evaluate their experiences along every step of their healthcare journeys. Maybe a survey on a patient's mobile phone asks for feedback moments after a he or she completes pre-registration or pays a bill online. Or, perhaps a customer service representative calls a patient to say, "I'm sorry that you encountered a problem during your visit this morning. How may I help?"

In truth, health care is not there yet, but as we scramble to catch up with other consumer-oriented industries, it is becoming ever more clear that healthcare organizations must commit to capturing, understanding, and acting on each patient's individual experience.

Consumerism in action. There is no question that patients are taking on more financial responsibility when it comes to their health care. For consumers who buy insurance through state or federal exchanges, the average deductible for silver plans this year is $3,064, and the average for a bronze plan is $5,765, according to the Kaiser Family Foundation.a Meanwhile, the average annual deductible for single coverage through an employer-sponsored plan is $1,318, with higher deductibles for family coverage. Most Americans are probably not prepared to spend that much money on their health and bank on the fact that they will not have to—they assume they will remain healthy. Even if they don't have to spend the full deductible, they will expect high quality, convenience, and responsive customer service for the price tag, and they will respond when they find it lacking. In fact, just one element of service—a health system's billing processes—can have a powerful impact on patient perceptions and loyalty.

The Connance Consumer Impact Studyb, an online survey of 500 healthcare consumers in 2014, found that:

  • 82 percent of respondents who gave a top satisfaction score to a recent hospital billing experience said they would recommend the hospital—but only 15 percent who were less than satisfied would recommend the organization.
  • 95 percent of consumers who were highly satisfied with the billing process said they would return to the same hospital for a future elective service; only 58 percent of those who were not satisfied would do so.
  • 74 percent of respondents who gave the top rating to their billing experiences paid their bills in full. Of those who were less than satisfied, only 33 percent did that.

Laurie Hurwitz, executive director of revenue cycle at Gundersen Health System in La Crosse, Wis., says those findings underscore the attitudes about healthcare providers that she sees in her adult children and other young adults. "They are busy and not overly loyal to their healthcare providers," she says. "They want what they want, when they want it, where they want it, and at a price they're willing to pay. That means an easy billing process would actually be a differentiator that would cause them to switch providers."

Patient experience defined. Although capturing the patient perspective has long been standard practice for many industries, such as retail, hospitality, and banking, that is not the case in health care. The field is relatively green, and provider organizations of all sizes are in a learning mode about what information to capture, how to measure it, and how to act on it to earn their patients' loyalty.

Indeed, the term "patient experience" was defined just two years ago, when researchers at The Beryl Institute published this definition: "The sum of all interactions, shaped by an organization's culture, that influence patient perceptions across the continuum of care."c

The definition was drawn from a review of literature published in the previous 14 years, which revealed several concepts that underscore the complexity of the issued:

  • Patient experience includes events and occurrences that happen independently and collectively across the continuum of care.
  • It is more than patient satisfaction; thus, relying on satisfaction surveys is insufficient.
  • Addressing patient experience requires focusing on each patient's individual circumstances and needs.
  • The concept is tied to a patient's expectations and whether they are positively realized, regardless of clinical outcomes or health status.

Understanding these points, Integris Health, the largest integrated healthcare system in Oklahoma, considers patient experience on two fronts. "We have adopted the philosophy that the patient experience is like a railroad track, and there are two rails: the clinical experience and the operational/financial experience," says Greg Meyers, system vice president of revenue integrity. "In the end, we think if both rails aren't equally effective, the patient is not going to get to where he or she wants to go."

Many other health systems share that perspective, as can be seen by the more than 1,500 respondents to The Beryl Institute's 2015 survey, which documents the emerging patient experience movement.d Among the findings:

  • 52 percent of hospitals and 43 percent of physician practices identified patient experience as one of the organization's top three priorities for the next three years.
  • 47 percent of hospitals and 45 percent of physician practices reported having a formal definition of patient experience.
  • 83 percent of hospitals and 82 percent of physician practices have a formal structure for addressing patient experience.
  • 58 percent of hospitals and 52 percent of physician practices have a formal mandate/mission that guides their patient experience efforts.

The job titles of the survey respondents tell their own story. In 2013, just 22 percent of respondents to a similar survey were "experience officers," whereas 26 percent identified themselves as a committee/team, and 8 percent were chief executive officers. By 2015, 42 percent of respondents were "experience officers," documenting how rapidly that position has grown.

Similarly, 28 percent of the 2013 respondents reported they had no full-time staff members designated to support patient experience; by 2015, 33 percent of respondents reported having five or more full-time staff.d 

The rapid growth of leadership and staff to focus on patient experience shows that leading health systems value their patients' perspectives and are committed to using their feedback to improve encounters going forward.

"We must continually search for new ways to understand what patients think," says Stephanie Wells, system vice president for revenue cycle and HIM at Ochsner Health System in New Orleans. "In this day and time, not listening to the patient leaves you open to missing a great opportunity to move things forward and do things better."

Narrowing Satisfaction Blind Spots

For most organizations, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is the standard method for assessing what patients think. Developed by the Centers for Medicare & Medicaid Services (CMS), this 32-question assessment is administered within a few weeks of inpatient discharge and asks individuals to rate several components of their experience, such as the cleanliness of the bathroom and the quietness of the care environment at night.

The survey results help consumers compare hospital options. A subset of each hospital's HCAHPS scores is published on the government's Hospital Compare website. CMS also publishes "star ratings"—between one and five stars, reflecting a hospital's overall score—to make comparisons easier for patients.

Because hospitals participating in the Medicare program are required to use HCAHPS, it often serves as a method to tie a provider's care quality with payment. The scores figure into the Hospital Value-Based Purchasing formula that is used to calculate each organization's Medicare reimbursement.

HCAHPS can also enable comparisons between organizations. Due to the survey's standardized instrument and data-collection process, hospital leadership can benchmark performance against other hospitals and identify opportunities for improvement.

Despite its prominent role, the HCAHPS survey is limited by the fact that patients are surveyed only one time and asked about just a few elements of their experience. Noticeably absent are any questions about patient access to services, scheduling, registration, billing, payment processes, or myriad other revenue cycle functions that require much time, attention, and effort on behalf of patients. One could argue that a patient's experience with the revenue cycle is equally as impactful as his or her interactions on the clinical side, and questions assessing this experience are essential.

"Patients expect to feel pain when recovering from an appendectomy, so they will likely not blame the providers if they experience discomfort; however, if the billing process proves to be a pain point, that sticks in the patient's mind," says Corey Meyer, director of patient access and virtual health at Lancaster General Health System in Lancaster, Pa. "The billing process is the last impression patients have with us, and, if they have a bad financial encounter, that is potentially the final impression."

What patients care about. In 2013, McKinsey & Co. asked patients who had been hospitalized within the past three years to identify the factors that were most important in influencing their satisfaction with the hospital experience.e The researchers then compared those responses to the patients' satisfaction levels to determine the relative importance of each factor.

The results were not necessarily predictable: Three factors—nurse empathy, keeping the patient informed, and doctor empathy—were all more significant to the patient's satisfaction than the outcome of the procedure or care. Other influential factors included administrative simplicity, having a single point of contact, the ease of understanding the bill, and straightforward scheduling—to name a few. There were many items in the list that the HCAHPS survey does not address, underscoring how easy it is for providers to have "satisfaction blind spots" if they do not proactively seek feedback about a wide range of patient interactions that are not assessed via other methods.

"Every touchpoint with customers across the entire care journey—including the thoughts, feelings, and impressions from the appearance of a facility; the interaction with every staff member; the feelings after an encounter; and their digital experience with an organization—all of these factor into the total customer experience," says Paul Alexander Clark, founder of Curate Health. "When you open up your mind to see that the customer and patient experience is so broad, you realize that to improve it, you need to measure it."

Timeliness is critical. The timing of the HCAHPS survey is also a potential limitation because patients are not asked for their feedback until well after the encounter. At this point, their frustration could have amplified or diminished, yielding a less-than-accurate portrait of the patient's experience. Conversely, if patients are asked to provide feedback immediately after an interaction, they are more likely to respond, and the information has a greater chance of being a true reflection of patients' impressions.

Gundersen Health is working to make their surveys timelier, asking every patient who makes an online payment to take a brief survey following payment that includes the question, "How likely is it you would recommend Gundersen Health to a friend or colleague due to your recent payment experience?" About 20 percent of consumers respond, Gundersen's Hurwitz says, and 78 percent give the billing experience a top rating on a five-point scale.

Brigham and Women's Health Care is also focused on this task. The organization recently switched from paper surveys mailed to patients about three weeks after a visit to email surveys distributed within 48 hours. The survey measures patients' satisfaction in six categories: access to care; experience during the visit; nurse/assistant; care provider interactions; personal issues; and overall assessment. "We saw a 50 percent improvement in the number of survey responses in the first month, and an equivalent number of additional comments," says Richard Fernandez, senior vice president of ambulatory services for Brigham and Women's. "It was astounding the difference getting the survey out faster could make."

Ochsner Health System has also implemented more real-time patient satisfaction surveys. At the end of each customer service call, for instance, the caller is invited to complete a phone survey to assess his or her satisfaction with the interaction. "We take that data and say, what can we do to help our customer service team excel?" Ochsner's Wells says. "For example, we created an online search tool for our policies so we can help our phone reps be faster with their responses."

The organization also built the customer service survey data into a performance-management tool and uses it to evaluate the performance of each customer service representative, as well as the supervisors, managers, and directors of each team.

Move beyond clinical content. Because HCAHPS is not optimal for collecting information about the patient financial experience, organizations must look to other methods. For example, quantitative patient surveys—conducted by mail, telephone, email, or integrated into online checkout—are the most common methods of gathering quantitative data about revenue cycle interactions.

Organizations can also leverage qualitative methods, including convening focus groups, asking a health system's patient and family advisory council to provide feedback, or setting up a phone line and asking patients to call in.

Lancaster General invites consumers to record their compliments or concerns on its "Care to Share" telephone line. A message from the CEO is posted on the hospital's website: "Hearing about your experience in your voice will help us recognize what we are doing well and make improvements in areas where we may have fallen short."

Adapting and Responding to Patient Feedback

Gathering patient input is only helpful if organizations use the information to improve processes. "Everything we do needs to center around the patient and, from a revenue cycle standpoint, we want to make sure that we give the patient a financial experience that's commensurate with their clinical experience," Ochsner's Wells says. "So, we must continually evolve, and the only way we're going to do that and meet the expectations of our patients is if we listen to them."

In the following sections, healthcare leaders share how they are responding to patient feedback and working to elevate the patient experience.

Improving access. Brigham and Women's Hospital uses patient satisfaction survey results to enhance access. "Our biggest improvement opportunities involved making it easier to get a practice on the phone, the convenience of office hours, scheduling appointments, courtesy of staff at check-in, and courtesy of staff members who schedule appointments—it's all those interpersonal skills," Fernandez says.

As a result, he is building a team to work with practices on strategies to improve access and the patient experience. The team will focus on the highest-volume practices with the most challenging access issues, and they will use various strategies—scripts, tools, capacity analysis, and staff training—to enrich patient interactions. "It's clear that our patients want to come to the Brigham, which is great, but they may not be willing or able to wait the amount of time that it takes to get an appointment, and that is an area that we can improve in," he says.

Being more transparent. Brigham and Women's is also joining the growing number of health systems that are sharing consumer feedback about physicians with the public to support transparency and enable physician engagement. Because the information is posted publicly, physicians tend to have heightened concern about their patients' perceptions. "From what I'm hearing, this is a pretty powerful tool to get providers engaged in improving both the clinical and financial experience," Fernandez says. "Patients appreciate when a provider says, before leaving the room, 'If you want that prescription refill in six months, feel free to use the portal,' or, 'I appreciate your comments. You'll probably get a survey within two days. Let us know how this visit went.'" Three services at Brigham and Women's are piloting the transparency project, and Fernandez hopes to extend it across the organization by the end of this year. Physicians in the pilot phase have found that, in general, comments and ratings are overwhelmingly positive.

Streamlining patient statements. For many organizations, the billing statement represents an opportunity for improvement. Ochsner Health System, for example, committed to overhauling its billing statements based on a review of the root causes of patient calls. "We thought that our statements were incredibly instructive, but, after looking at the reasons for calls, we found that having so much information on our statements was confusing," says Katherine Cardwell, assistant vice president of revenue cycle. "So, we did an initiative to simplify our statements and make sure we are providing the information that patients want to see, but in a format that is not overwhelming." For example, patients indicated that they wanted physician names to appear on the statement, so the organization made the change.

Integris Health has also done significant work on its billing statements. When the organization was evaluating vendors for a new clinical/financial information technology system, the marketing department convened a consumer focus group as part of the decision-making process. The goal was to identify what consumers wanted the health system to do differently and determine how a technology vendor could enable those improvements.

"The main thing that came up is that our consumers not only want to see a hospital bill that's easier to understand, they want a bill that presents as much of a total picture as possible on one document," Integris's Meyers says.

That patient perspective made it clear that Integris needed to choose an IT vendor that could support a consolidated patient statement. With that decision made, revenue cycle leaders used a series of focus groups to get input on how the statements should look, what information they should provide, and how they should be distributed.

The ways consumers influenced the health system's financial communications include:

  • After focus group participants pointed out that the written notices from Integris that indicate the patient's insurance company has been billed were a waste of paper, the organization stopped issuing these notices, eliminating about 50,000 mail pieces each month.
  • Focus group members also signaled that patients do not understand which physicians are employed by the health system and which are independent. As a result, Integris added some clarifying language to its statement, mentioning that it only covers certain doctors, and the patient will receive a separate bill from other doctors not employed by Integris.
  • The organization removed unnecessary details from the statement, and the new version shows what the patient owes in four categories: physician fees, hospital charges, home health or other services, and payment plan installments, if applicable.

Improving online bill-pay. As consumers rely on technology to make their healthcare financial experiences more efficient, it is critical that organizations have strong and positive online presences. People accustomed to shopping on Amazon and other consumer-savvy retail websites get frustrated with the clunky interfaces they often encounter in their dealings with healthcare providers. Beyond that, consumers don't understand why they can shop for and purchase airline tickets and hotel rooms easily online, but accessing healthcare services typically requires multiple telephone calls to schedule an appointment, obtain a price estimate, verify insurance coverage, and seek help in understanding the bill.

"We would receive feedback on our online tools, and the patient financial experience was not especially good," says Meyer, the Lancaster General access director. "It was very complex and confusing for something that should be simple, so we wanted to raise patient satisfaction."

Lancaster General is in the process of making improvements, striving to offer self-service online price estimates, scheduling, insurance validation, check-in, bill-pay, and payment plans. "We know that patients want to be able to do things 24/7," Meyer says. "They want to pay their bills when they need to, and they don't want to have to call to give their credit card information over the phone. Letting patients handle these things online shows that we value their time."

In 2014, Lancaster General also upgraded its online bill-pay platform to make online statements easier to understand and allow patients to set up payment plans themselves. The technology provides the hospital with patient feedback through an e-survey offered immediately after the patient pays a bill. Of those responding to the survey in the first few months after go-live, 82 percent said they would recommend Lancaster General based on their billing and payment experience.

The e-survey also serves as a source for faster insights. For instance, in the open comment field, a patient's complaint—"First tried calling to make payment and was on hold 10 minutes both times I called. Very frustrating. Paying online was easy."—highlights the need to improve call response times.

Catching Up With Other Industries

Although best practices for collecting and using patient experience information to enrich the healthcare encounter are still emerging, leading provider organizations recognize the need to embrace consumer feedback and respond to it. As such, they are working hard to capture information more quickly and comprehensively than ever before. Every point throughout the patient journey is an opportunity to collect feedback and gain an understanding of what's going on. Organizations need to leverage these opportunities to stay relevant, competitive, and consumer-focused for the future.


About Simplee

Simplee® is transforming the patient financial experience. The Simplee Financial Engagement™ software platform is the world's first single enterprise solution for patient engagement, estimates, billing, payment, and financing. With Simplee, healthcare providers get award-winning technology (Fierce Healthcare, Webby, etc.) that creates a payment experience patients (and staff) love, driving satisfaction, payments, and more.

Today, Simplee serves more than 777 healthcare providers nationwide, across 20 states, processing more than $1 billion in patient payments annually.


Footnotes

a. Rae, Matthew, et al., "Patient Cost-Sharing in Marketplace Plans, 2016," Kaiser Family Foundation, Nov. 13, 2015.

b. Press release, "2014 Connance Consumer Impact Study Shows Link Between Business Office, Patient Payment Behaviors, and Patient Satisfaction," Connance Inc., Waltham, Mass., Dec. 2, 2014.

c. Wolf, Jason, et al., "Defining Patient Experience," Patient Experience Journal: Vol 1, Issue 1 (2014).

d. Wolf, Jason, "State of Patient Experience 2015: A Global Perspective on the Patient Experience Movement," (2015).

e. Carrus, B., et al. "Measuring the Patient Experience: Lessons from Other Industries," white paper published by McKinsey & Co., August 2015.

Publication Date: Sunday, May 01, 2016