"We know people can come here and have life-saving care, but if they are still fighting about a bill or they are upset about a charge three or four months after the fact, that financial experience can wipe out their satisfaction with the entire clinical experience," says Greg Meyers, system vice president for revenue integrity at INTEGRIS Health.
That is why INTEGRIS Health, a 13-hospital system based in Oklahoma City, has spent the past five years systematically working to improve the way patients interact with revenue cycle functions. This year, the system is developing a new survey to measure patient satisfaction with various administrative and financial interactions before they arrive at the hospital and after they leave.
This case study appears in the Leadership special report, Creating Value for Patients for Business Success.
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"We have created an institutional emphasis on making sure that we offer a quality operational and financial experience that goes side by side with the quality clinical experience that we're providing to patients," says Meyers.
In 2005, INTEGRIS Health used the Lean process improvement methodology to conduct a value stream analysis of its revenue cycle functions to understand the patient's perspective.
That exercise identified areas that needed improvement. To decide how to improve, Meyers and his team focused their attention outside of health care. "If people would think of health care as being a business instead of a social service, some of these ideas kind of jump off the page," he says.
For example, registration kiosks are still novel in health care but have been used for years by airlines and other customer-focused industries. The hand-held credit card machine that INTEGRIS Health uses at a patient's bedside is a concept borrowed from rental car companies.
Meyers' initial impetus for focusing on patient experience was to increase INTEGRIS Health's competitiveness in the marketplace by making it easier for patients to comparison shop for healthcare services. INTEGRIS' Consumer Price Line is staffed by a call center that allows patients to learn their estimated out-of-pocket financial responsibility for various services prior to the service being delivered.
Since then, INTEGRIS Health has worked to add value to the patient experience by expanding access to revenue cycle functions so that patients have more control over how and when they deal with the administrative aspects of their healthcare services.
"We are really trying to get people into the system efficiently," he says. Patient-friendly features include the following.
Online self-scheduling for services, such as mammograms and bone density tests. Physicians' offices also have access to online scheduling so a patient can stop by the front desk after a doctor's appointment and have diagnostic tests and screenings scheduled immediately.
Online preregistration. An attempt to introduce online preregistration was disappointing because so few patients used it, says Meyers. Lesson learned: "We may have defeated ourselves by asking for so many data elements that patients may have said, 'Gee, I think I'll just answer this when I get to the hospital.' We probably could have asked for less information, made it more patient friendly, and gotten the ball rolling a little better."
Self-service registration kiosks. "If patients are pre- registered, they can complete the registration process in about 2½ minutes," says Meyers. "They can print out the forms, or we can email the forms to their homes."
Online business office. Patients can pay their bills online, get copies of their statements, update personal demographic or insurance information, and download a charity application any time of the day or night. That is supported by a call center that addresses patients' questions about their bill.
In addition to these patient-facing features, INTEGRIS Health uses some additional technologies that add value for patients, even though they seem invisible. For example, a software program uses information provided during preregistration to predict whether a patient will need charity assistance or establish a payment plan if they don't have the resources to pay their balance in full.
"That allows us to create workflows that reflect the amount of time, attention, and focus we need to spend with all patients to make sure they understand what their financial responsibilities are and to work with them to develop payment strategies," says Meyers.
Similarly, the patient registration process includes a registration accuracy software tool that monitors data entry for completeness and accuracy. That has significantly reduced the volume of returned mail and insurance denials for the system-and increased the number of accurate bills delivered in a timely fashion to patients. Registration accuracy now exceeds 99 percent at all INTEGRIS hospitals.
Like most health systems, INTEGRIS Health historically has had limited information about what patients think of its administrative services.
Focus groups were convened to learn what patients think about billing processes and hospital charging practices. This helped INTEGRIS identify ways it could help patients learn about the system. For example, the "Where does the dollar go?" feature on the system's website was developed in response to comments that the health system was getting rich off its patients. (See the exhibit below).
The only quantitative satisfaction data, however, has come from a few questions about the registration process that appear at the end of the kiosk registration process. That changes this year with the launch of a follow-up survey to measure patient satisfaction with the entire experience-from scheduling to billing. The survey, which is being developed internally, will be available on INTEGRIS Health's website.
"We will direct patients to the survey via information on our patient statements," says Meyers. "Our feeling is that patients are already routinely surveyed too much post-hospital. We would rather have responses from patients who proactively want to take the time to give us their feedback."
As the level of service provided to patients has increased, the responsibilities of the revenue cycle department have steadily grown. Meyers says staffing levels have remained constant in recent years, but productivity has improved significantly. One of the key metrics used by INTEGRIS to measure productivity is "cost to collect."
"We have been able to reduce that amount by 18 percent over the past several years," he says.
That is due, in part, to better training. All revenue cycle staff are expected to complete a two-year, 26-module online revenue cycle curriculum. The off-the-shelf program has been customized so that it includes INTEGRIS' forms and policies.
Also, Meyers has recruited key revenue cycle leaders from outside the healthcare industry, specifically turning to the telecommunications industry. Those individuals have a broader understanding of customer service and the use of technology to improve the customer experience than most healthcare staff members commonly do.
One of Meyers' top priorities going forward is to improve the compensation of front-end staff members and to see them recognized throughout the organization as the highly trained professionals they are. He believes that hospitals have not recognized how significantly registration staff's jobs have expanded in the last few years.
"I often tell our leadership that employees who work in the registration area are the front-desk clerks at the most expensive hotel in Oklahoma City," he says. "They have to have customer service skills, they need to understand regulatory issues, and now they have to ask people for money. It's really a difficult job."
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