Leveraging Patient Segmentation to Meet Patients Where They Are

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Presentation transcript:

Leveraging Patient Segmentation to Meet Patients Where They Are Kathie Kirkland, PFS Director, Maricopa Integrated Health System Erica Franko, Senior Vice President and Managing Director, Advisory Services, nThrive

Maricopa Integrated Health System

KS The Situation Precyse MedAssets MedAssets + Precyse Merge MedAssets + Precyse Equation Health / Adriema / e4e MedAssets Splits Acquired ½ Divested Brand Created The Situation KS

What is Patient Access? Patient Access is the start of the Revenue Cycle value chain What are the aims of a successful patient access program? From contact… Eligibility & Benefits Address & ID Verification Registration Patients are scheduled with the right provider at the right time Scheduling Call center ED registration Insurance Verification Patient Liability Estimation Patients are financially cleared prior to arrival Patients understand their liability and have an opportunity to pay …to arrival Service Collections (pre- or point-of-service) Financial Counseling Authorization Patients receive the support that they want and need on their journey

Patient Perspective of Patient Access Access/coverage determination Enrollment qualification Post-service account resolution POS account resolution Estimation of liability/propensity to pay $ Each area of interaction impacts what the patient will or will not receive as a liability

Which trends align with Patient Liability? Complex Reimbursement landscape Increase in Patient Responsibility $ Fate of health reform and alternative payment methods Shift of the cost burden from payors and employers to patients If common goods increased at the same inflationary rates as healthcare costs, one dozen eggs would cost about $55 Rise in Health Consumerism $ Rise in cost and utilization Growth in health care jobs and utilization has been greatest in ambulatory settings, while inpatient volume has been relatively flat. The rapid growth of various forms of population health models and convenient care drives toward an environment where health care is available on-demand at all times, in ways which increasingly transcend clinic walls. Many have noted that convenient care does not reduce utilization per se.  Innovations, technology, pharma and increased utilization (aging population) drive the cost to deliver and cost to collect Rising patient expectations for customer services in healthcare

What is Patient Liability? Patient Liability is the amount owed by the patient for services rendered due to a shift in the cost burden from payor to patient or to a lack of insurance Patient Liability impacts both the insured, underinsured, and uninsured and can take a variety of forms “True Self-Pay” Coinsurance Deductible Co-Pay Other Words for Patient Liability Self-Pay Self-Pay After Insurance Patient Responsibility Patient Portion Cost Sharing Point-of-Service Collections “What I Owe” $

What is Patient Liability? A conversational history 1998 2016 People are insured—that’s a good thing right? Of course, but with some complexity. Let’s think about the old approach—patients or consumers shared the burden of insurance premiums with their employers, with the employer bearing most of the cost. The Affordable Care Act (ACA) expanded coverage to millions of previously uninsured people through the expansion of Medicaid and the establishment of Health Insurance Marketplaces. 1. https://www.beckershospitalreview.com/payer-issues/cdc-nearly-40-of-us-adults-have-high-deductible-health-plans.html

What is Patient Liability? A conversational history Do we want? What is a high-deductible health plan? To put it in perspective, a high-deductible health plan is any plan where the patient is responsible for at least $1,350 as an individual or $2,700 as a family And it’s not just for the newly insured, the market saw a 3.2% increase in the number of high-deductible health plans offered by an employer Which brings us to today… 40% of American adults have a High Deductible Health Plan1 1. https://www.beckershospitalreview.com/payer-issues/cdc-nearly-40-of-us-adults-have-high-deductible-health-plans.html

How does Patient Liability impact our the market? Changing Payor Mix Increased Bad Debt Increased Cost-to-Collect “Self Pay” is now the 3rd largest payer behind Medicare & Medicaid1 30% of hospital revenue now comes from patients2 Patient liabilities are more complicated—no longer just co-pays—and include cost sharing arrangements like coinsurance and deductibles >80% of self-pay bills and 50% of patient responsibilities after insurance end up as bad debt3 A recent AHA survey indicates uncompensated care is a $35.7B industry problem4 25% of insured adults (31 million people) are considered under-insured and lack the ability to fund their care 5 Patient payments require more resources to collect downstream Providers can only expect to collect 50-70% of a balance after a patient visit6 From patients with high-deductible plans, providers are collecting about $0.18 to $0.34 on the dollar7 [1] National Assn of Healthcare Access Management; [2] InstaMed, Trends in Healthcare Payments, Sixth Annual Report: 2015; [3] ZirMed webinar; [4] Health Forum, AHA Annual Survey Data, 1990-2016 ; [5] Commonwealth Fund Biennial Health Insurance Survey; [6] Trends in Healthcare Payments Annual Report, 2015; [7] http://www.grouponehealthsource.com/blog/are-you-ready-for-self-pay-patients-in-2016

Who pays the bill? Won’t insurance pay the bill? Medicare pays an average of 20-40¢ on the dollar That means for an office visit of $100, a doctor/hospital will be reimbursed $20-40. With all the costs incurred (supplies, salaries, etc.) do you think a hospital makes money treating Medicare patients? Managed Care pays an average of 50-80¢ on the dollar That means for an office visit of $100, a doctor/hospital will be reimbursed $50-80. With all the costs incurred (supplies, salaries, etc.) do you think a hospital makes money treating Medicaid patients? Medicaid pays an average of 10-30¢ on the dollar That means for an office visit of $100, a doctor/hospital will be reimbursed $10-30. With all the costs incurred (supplies, salaries, etc.) do you think a hospital makes money treating Medicaid patients? Patient Cash varies from 0-30% of charges Contractually, insurance companies shift reimbursement (to hospitals) from themselves to the patients. Hospital rely on these “Patient Liabilities” to maintain their mission statements (Providing care to the communities, etc.) and in some cases, to keep their doors open. This amount is rising as high deductible plans become more prevalent

Patient Responsibility Service Level Expectations Symbiotic relationship between patient liability and service level expectations High level of patient responsibility and high service level expectations As the cost burden shifts to patient responsibility, the expectation of payment increases… Patient Responsibility …along with patient expectation of service levels—wait times, customer service, responsiveness LOW HIGH LOW HIGH Service Level Expectations

Qualities Consumers Value in Companies A McKinsey study found that health care consumers and non-health care consumers are aligned on performance expectations Qualities Consumers Value in Companies % of respondents (N=2,255)

Patient Segmentation Today Patient schedules appointment Opportunity to optimize workflow and patient experience No Insurance Financial counseling if coverage is not provided by patient OR if insurance cannot be verified Insurance Patient pays co-pay at POS or payment plan, charity care, or other plans are created FINANCIAL CLEARANCE Verifies insurance coverage, checks eligibility/benefits for scheduled service, obtains authorization and estimates patient liability

Consumer-Driven Patient Segmentation Financial/Payment Risk The new age of patient access requires strategies that address the patient as an individual consumer High Touch Low Risk High Touch High Risk Patient Engagement Low Touch Low Risk Low Touch High Risk Financial/Payment Risk

Patient Engagement in the Revenue Cycle High Touch, Low Risk Complex care plan Complex or incomplete benefit plan Secondary coverage enrollment: Disability Enrollment, Managed Medicaid etc High Touch High Risk Uninsured patient requiring support to apply for Medicaid, Disability, Charity care and other programs Underinsured patient with complex care plan and low ability to pay Low Touch Low Risk Simplified care plan Comprehensive benefit plan Connected patient preferring electronic and self-service interactions Low Touch, High Risk Underinsured patient with ability to pay History of non-payment post service Patient Engagement Required Financial/Payment Risk The new age of revenue cycle requires strategies that address the patient as a consumer

Connecting the Patient Revenue Cycle Patient Experience Access/coverage determination Enrollment qualification Post-service account resolution POS account resolution Estimation of liability/propensity to pay $ Cash Collections Productivity

Reduce Cost by Investing in Advanced Segmentation Reduce employee turnover through alignment and training of colleagues Reduce financial risk by addressing liabilities before they become resource-intense to collect Defer low-touch patients to automatic/digital channels Utilize high-cost resources effectively through deployment of scheduling algorithms

Contributors to Success Service Attribute Impact Singular focus on helping with bills and insurance Extends capabilities of your staff – does not duplicate efforts Proactive service to review all bills and insurance statements Improves the patient experience, increases and accelerates collections Service covers ALL bills, including outside physicians, labs, and pharmacies Patients appreciate the comprehensive service Improves physician relationships, as benefits extend to their practices Utilizes technology and patient portal Create transparency and ease of communication with patients Independence Patients trust their advocates, which increases satisfaction and enables collection Its important that staff know they are the subject matter experts. They need to be well versed in Insurance and adjudication (gross vs. allowable vs. benefits applied to total amount owed). Being able to speak to these topics establishes credibility which impacts patient sat and effectiveness in collections. Scripting is the largest contributor to success IMO..

Measuring Success

Erica Franko Senior Vice President and Managing Director, Advisory Services efranko@nthrive.com