As a result of many of the initiatives under health care reform, significant operational and financial issues have been encountered by hospitals and are being addressed. In addition to these issues, health care reform will have a significant impact on the operations of the revenue cycle. Its effect will not be limited to the impacts associated with reductions in payments: less staffing and fewer resources. The following addresses some of the potential impacts associated with Accountable Care Organizations (ACO) and Value Based Purchasing (VBP) on the operational and customer service burdens in the Revenue Cycle.

Various initiatives under the Patient Protection and Affordable Care Act and other demonstration projects are quickly gaining momentum. The following is a brief summary of some of the initiatives and some of the potential impacts that they will have on revenue cycle operations.

Accountable Care Organization

An Accountable Care Organization (ACO) is a primary care centric organization that may also include specialists and hospitals. The focus of the ACO is to improve the health of its members by providing preventative care. The ACO is required to meet 65 physician oriented measures in five domains including the patient's overall experience of care, and, based on the results, it may be eligible for incentive payments or subject to penalty. As a result, it is important for hospitals to plan to assist the ACO in improving the patient experience of care. Significant time and effort will be spent in ensuring that clinical staff is adequately trained in customer service; however, often the patient's first and last encounters with the hospital are typically with the Patient Access and Patient Financial Services departments, respectively. As a result, a bad experience in scheduling, registration or billing may have a negative impact on the patient's experience thereby resulting in negative patient satisfaction surveys and complaints to the PCP. These survey results may also have a negative financial impact on the ACO by either reducing or eliminating the incentives. In addition, if the patients are complaining to the Primary Care Physician (PCP) about the hospital, the PCPs are likely to refer their patients for diagnostic testing to other facilities where the patient's feel they have had better experiences, and the PCP hears fewer complaints.

Value Based Purchasing

The VBP was designed to transform the Centers for Medicare and Medicaid Services (CMS) from "a passive payer of claims" to an "active purchaser of quality health care." This transition is being implemented by CMS through the active moderation of 18 quality of care measures. In addition to measuring clinical practices, the VBP will also utilize 8 domains from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey tool. As noted above, a single negative patient experience may have a significant impact on the overall patient survey; therefore, it is imperative that all efforts be made with not only clinical staff but with scheduling, registration, admissions and billing, to ensure that all staff is properly trained in customer service and that there is a concerted focus on ensuring a positive customer experience for the patient and patient's family.   Failure to properly train staff may result in a completely negative survey being returned by the patient which could potentially lead to reduced reimbursement for the hospital.
 
Challenges
  
The goals of the ACO are to improve the patient's health while concurrently reducing the cost of care. Patients will be assigned to ACO's, and the PCPs within the ACO will have the ability to direct each patient's care and refer the patients to the specialist and hospital that are part of the ACO. However, unlike capitation, the patient can decide to seek care from other providers that are not part of the ACO. Under the ACO model, the patient can go to any hospital or any specialist, whether they are part of the ACO or not, without any financial penalty being incurred by the patient. As a result, if the patient has a bad experience scheduling a radiology test or had a billing issue at the hospital, the patient can choose to go to any other Medicare participating facility for either diagnostic procedures or potentially be admitted to another hospital. In addition, if enough patients voice their complaints to their PCPs or are hesitant to go to a specific hospital, it is likely that the PCP will begin to refer all of their patients to other hospitals that are not part of the ACO. This scenario could lead to failure of the ACO which would have a negative impact on both the relationship with the PCPs that are members of the ACO and also on the hospital's volume and financial results.

Both the ACO and the VBP focus on the patient's overall experience and quality of care. Under the VBP, the HCAHPS are a significant component of the hospital's overall score. This score will determine if the hospital is eligible for a so-called incentive payment. When patients or patients' families are filling out the survey, it is not unusual for a single negative experience with the Emergency Department registrar, the Admissions clerk or with the Financial Counselor attempting to collect a co-pay or obtain insurance information, to result in a completely negative survey. The challenge for hospitals will be to train Revenue Cycle personnel to recognize the importance that each encounter with a patient or patient's family could potentially have on the overall patient experience and the resulting financial health of the hospital.

Hospitals will also need to become sensitive to patients expectations. For example, to most patients that need diagnostic testing, speed is of the essence even though clinically a short delay may not have an impact on the outcome. As a result, if the ACO member hospital has a significant backlog of appointments and the patient has to wait 10 days for an appointment, it would not be unusual for the patient to call other providers and attempt to schedule an earlier appointment. As experience has taught us, if the patient is successful in scheduling an appointment at another facility, the patient may not cancel his initial appointment: this will result in additional testing backlog and an increase in patient no-shows at the ACO member hospital. In addition, this will lead to frustration for the PCPs, their patients will complain about the inability to schedule a timely appointment and hospital administration will question the loyalty of the PCPs because their patients are going to other facilities.

Lastly, the Revenue Cycle team has always faced a difficult situation: it has to be sensitive to the patient's health issues while also being responsible for the financial health of the hospital. Often times, patients and patients' families are rightfully concerned with the patient's health issues and will consider any attempt to collect money or insurance information as unimportant or insensitive to the patient. This can lead to the patient or his family feeling that the hospital's primary focus is business and not patient care.
 
Insights

Due to the changing nature of health care, hospitals will need to focus more time and attention on improving the patient's customer service experience. More times than not, the small things have a significant impact. For example, rather than giving a patient verbal or written directions to the radiology department, perhaps a volunteer could walk the patient to the destination and introduce the patient to the front desk person. To the extent that staff is trained and process is re-defined to focus on the needs of the patient, the patient's perception of courtesy and caring will yield significant benefit to the patient's perception of the hospital.

In order to accomplish these goals, significant amounts of customer service training will be required for revenue cycle personnel. The training should focus on the importance of each interaction of revenue cycle personnel with the patient or the patient's family, and how each interaction will impact the overall customer experience.Patients and especially patients' families find it difficult to discuss payment when their primary concern is for the patient's health. It will be necessary for revenue cycle personnel to be trained to recognize the situation and realize that it may be better to come back in an hour or in the morning when the situation has stabilized; rather, than to upset the family by continuing to pursue the issue. This will enable the patient or family members to focus on the issue at hand and focus on the payment and insurance issues when the situation has stabilized. Once the situation has stabilized, the information will be easier to obtain. Furthermore, training should also focus on the method of asking for information or dealing with difficult patients and recognizing the situation. Staff should always use the common courtesy of please and thank you and should always address the patient as Mr., Mrs. or Ms., and direct all questions to the patient, not the family member. One of the most difficult situations for a staff member is to remain calm, courteous and professional when those around them are not. Staff should be trained to diffuse a difficult situation rather than respond with anger. This will enable all involved to calm down and effectively address the issues.

In addition to the training focus, the hospital will need to address the issues relating to the scheduling of ACO patients. For example, should the ACOs' PCP have a direct number to the scheduling department and should slots be specifically reserved, up until the day before, for patients from the ACO? If a dedicated line is established, how should it be monitored? Should specific individuals in the billing office be assigned to follow up on ACO patients, and if possible, should billing questions from ACO patients be routed to specific individuals in the billing office? The hospital will have to devote time and resources to meet the specific challenges associated with meeting the needs of the ACO patients and their PCPs.
 
Summary

As a result of the changing nature of health care, either resulting from health care reform, greater patient needs and the financial stress on hospitals, customer service will continue to remain in the forefront of revenue cycle operations. It is important for revenue cycle staff to recognize the impact they have on the patient experience and the resulting financial health of the hospital. Hospitals will need to focus on training staff to enhance customer service skills on a regular basis and also to inform staff of the impact that the improved customer service has on the financial health of the hospital.
 
 
We are pleased to have the opportunity to provide this information to you.  If you have any comments or questions, please contact me at 484-840-1984.

Best Regards,

Ed Ladely
Director

Source: IMA Consulting