The Latest Self-Pay Trends: New Burdens and Opportunities
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Let athenahealth guide you through the burdens of navigating through revenue collections from your patients to make sure your practice has access to all monetary opportunities to ensure financial success.
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The Latest Self-Pay Trends: New Burdens and Opportunities
- 1. This event is live as of XYZ The Latest Self-Pay Trends: New Burdens & Opportunities Jessica Sweeney-Platt Executive Director Physician Performance Research
- 2. athenaResearch Learning from athenaNet 150M Automated messages delivered in 2014. 1.2B Data transactions processed annually. $4.2B Collections posted per quarter. 73,000+ Providers on our network. 69M+ Patient records.
- 3. 75 8580 9590 0500 1510 Source: Stampiglia, Tom. “Maintaining Profitability in the Era of Consumer-Directed Health Care.” Group Practice Journal. May 2009. Patient obligations account for 18% of provider revenue.
- 4. Continuing patient obligation trend 4 11.4 M 2011 10 M 2010 13.5 M 2012 15.5 M 2013 17.5 M 2014 Number of People with High Deductible Health Plans
- 5. Obligations for commercially insured patients rising fast 5 $44.19 $47.58 $50.06 $52.59 $55.40 $0.00 $20.00 $40.00 $60.00 2010 2011 2012 2013 2014 Average Obligation for Visits with Non-Zero Patient Responsibility Same-store, among providers active on athenaNet since 2010 n = 2,013 providers
- 6. This trend is putting health care costs out of reach for an alarming number of people 6 Percentage of Households with Deductibles Exceeding Liquid Assets 37% 49% Mid-range Plan Deductible High-range Plan Deductible $1,200 $2,400 $2,500 $5,000
- 7. Large obligations more common for commercially insured patients 7 74% 67% 15% 19% 11% 14% 2010 2014 Under $40 $40 to $100 Over $100 Proportion of Visits by Obligation Type (Excluding Zero-Obligation Visits) Same-store, among providers active on athenanet since 2010
- 8. Practices fail to collect tens of thousands per physician annually 8 $66,863.20 $31,713.07 $23,357.56 $17,136.00 $8,323.89 80th Percentile 60th Percentile Median Provider 40th Percentile 20th Percentile Uncollected Patient Revenue for a Fully Allocated Provider, 2014
- 9. Uncollected patient revenue per provider for selected specialties 9 $0 $20 $40 $60 $80 $100 $120 $140 $160 $180 $200 Orthopedic Surgery General Surgery Cardiology Urology Gastroenterology OB/GYN Neurology Dermatology Family Medicine Internal Medicine Pediatric Medicine (thousands) Median $12k $13k $18k $20k $25k $28k $36k $43k $46k $56k $60k Third QuartileSecond QuartileBottom 10% Top 10% Distribution for a Fully Allocated Provider (2014)
- 10. Uncollected patient obligations per provider and per practice 10 1 to 6 Providers 7 to 20 Providers 21 to 150 Providers 151 or More Providers Per Practice Top Quartile $10,230 $83,490 $308,772 $2,264,681 Median $26,239 $160,884 $653,111 $3,523,769 Bottom Quartile $59,858 $307,364 $1,240,754 $6,986,078 Top Quartile, Median, and Bottom Quartile Performance By Number of Providers in Practice
- 11. The relationship between the practice and the patient has changed.
- 12. The relationship between the practice and the patient has changed.
- 13. What is Patient Pay Yield? Payments collected within 5 months 13 Patient Charges Patient Pay Yield Patient charges not collected within 5 months represent true loss – and a real opportunity to improve revenue on an ongoing, monthly basis.
- 14. Best Practices for Improving Patient Collections Staff Training & Accountability1 Pre-Visit Collections Strategy2 Time-of-Service Collections3 Ongoing Collection Efforts4
- 15. 1 Staff Training & Accountability Targeted Staff Training Impact: High Effort: High Ongoing Staff Accountability Impact: High Effort: Moderate What: Educate and train staff on all aspects of payment to become well-versed authorities on insurance benefits, payment policies, and importance of patient collections. How: Develop training curriculum for staff, using scripted materials and additional training for front-office tools as practice. Upside: A rigorous approach to training can drive real, measurable financial improvements. What: Regularly assess staff members’ interactions with patients to ensure collections are being followed through on correctly. Provide support or re-training as needed. How: Staff-specific metric scorecards, ongoing monthly reporting and evaluations, and meaningfully linked measures of accountability. Upside: Strong staff audit performance corresponds directly with a well-functioning front office. 15
- 16. Premier Family Care • 30-physician family practice based in Florida • 84% of overall patient obligations collected • 82% of copays collected at the time of service • Noticed in February 2015 copays and outstanding balances were frequently uncollected at the time of service
- 17. Case Study: Premier Family Care 17 Targeted Training Improved Average Collections, Reduced Variation Outstanding Balance Collection Rate at Checkout, by Staff Member
- 18. 2 Pre-Visit Collections Strategy Pre-Visit Financial Review Impact: High Effort: Moderate-High Patient Financial Obligation Estimates Impact: High Effort: Moderate What: Review patient accounts 1-2 days before scheduled visits to determine the best way to handle collection attempts for patients with large outstanding balances. How: Provide staff with appropriate guidance training and support materials. Upside: Practices that collect outstanding balances at the time of service ted to have a very high overall patient collection rate. What: Without estimating in advance, practices cannot collect the full patient portion and must rely on patients to pay after receiving a statement 30 days later, when the likelihood of full collection is significantly lower. How: Review patient records in advance to estimate a patient’s obligation for expected services, typically for high-cost scans and procedures . Upside: Estimates allow practices to collect the full anticipated obligation before or at the time of service .
- 19. 19 OKC Obstetrics and Gynecology • 20-provider practice • Overall patient obligations yield on patient obligations of 79% • Practice administrator reviews all patient accounts two days in advance of appointments and calls patients with outstanding balances over $100
- 20. Case Study: OKC OB/GYN 20 Outstanding Balance Collection Driving Impressive Patient Collections Frequency of Outstanding Balance Collection at Time of Service Compared with Overall Yield OKC OB/GYN vs. Others, > 5 providers, > $20k/month in Outstanding Balances at Time of Service
- 21. 3 Time-of-Service Collections Card on File Agreements Impact: High Effort: Low-Moderate Large-Balance Payment Plans Impact: Moderate Effort: Low What: Particularly useful when patient obligation is unknown but within an acceptable range agreed upon by the patient. How: File patient credit cards to pay newly incurred balances before a claim is processed. Upside: Incorporating card on file can result in a higher patient pay yield. Success with credit card collections at urgent care centers indicates this can be a viable collection approach. What: Practices should consider offering payment plans by default for insured patients with balances over $500 and uninsured patients with balances above $150. How: Offer payment plans to patients with large or unmanageable balances, allowing them to pay obligations over a period of time, ideally within six months. Upside: Payment plans are essential for increasing overall collections, especially for practices with high-cost visits and patients responsible for a substantial portion of the total cost of care.
- 22. 22 Florida Woman Care • After promoting card-on-file, the number of card-on-file contracts grew from 1,200 to more than 2,000 per month • Encounters without a card on file, FWC collects about 70% of patient obligations • Encounters with a credit card contract, the group collects 81%
- 23. Case Study: Florida Woman Care 23 Incorporating Card on File Into the Checkout Workflow Number of Card on File Agreements per Month at UPM (2015)
- 24. 3 Time-of-Service Collections Standardized Down Payments Impact: Moderate Effort: Low Collection-Focused Digital Check-In Impact: Moderate Effort: Moderate What: Most helpful for high-cost visits or practices with a high rate of uninsured patients. How: Collect a down payment from patients when the patient obligation can’t be reliably estimated in advance. Upside: Practices are guaranteed to recover at least some money from patients who might otherwise fail to pay after visits, with minimal risk of overpayment. What: Digital check-in tools are dedicated kiosks, such as tablets or single-purpose hardware devices, that handle a variety of front desk tasks with minimal or no hands-on staff time. How: Installing dedicated kiosks, tablets, or single-purpose hardware devices that handle a variety of front desk tasks with minimal or no hands-on staff time. Upside: Digital check-in can help practices capture patient demographic information and social, family, and medical histories.
- 25. 25 Keystone Orthopedic Specialists Proportion of patient visits with complete registration information increased from 17% to 53%--with significantly less staff time Payments by credit card more than doubled Co-pay collection increased by 8%
- 26. Case Study: Keystone Orthopedic Specialists 26 Phreesia Driving Improvements Across the Front Office Workflow Percentage Point Change Before and After Implementing Digital Check-In “Our collection of patient obligations has significantly increased since we started using Phreesia with athena... it’s cut down the time our staff spends registering patients. It also makes patients more responsible for the information they give you. —Office Manager, Keystone Orthopaedic Specialists
- 27. 4 Ongoing Collection Efforts Unpaid Balance Follow-Up Impact: Moderate Effort: Low Portal Collection Campaigns Impact: Moderate Effort: Low What: When a balance is transferred to a patient after a visit, athenahealth sends monthly statements to the patient unless the practice elects not to do so . How: Contact patients with outstanding balances to collect payments or discuss payment options. Send unpaid accounts to collection agencies, as needed. Upside: Taking steps to intensify follow-up efforts with patients presents significant collection opportunity, particularly in practices with large uncollected obligations. What: Promote the patient portal as a central place to view statements and make payments. How: For patients with large outstanding balances, use patient outreach tools to direct them to the portal. Upside: Communicating and using the portal’s payment functionality has been shown to boost patient pay yield and reduce self-pay DAR. High portal adoption rates can also increase patient loyalty and lower administrative expenses.
- 28. Summit Medical Group • Independent, multi-specialty medical group based in New Jersey • implemented the athenaCommunicator portal in mid-2014 • In eight months of introducing the portal, Summit’s adoption reached 50%
- 29. Case Study: Summit Medical Group 29 Improvement in Patient Financial Metrics, Summit Medical Group “We were surprised by how many people are paying through the portal. We didn’t really encourage patients to do that—they just found it more convenient.” —Practice Administrator, Obstetrics and Gynecology Practice
- 30. 30 The athenahealth Solution 30 Reminder Calls Payment Estimator Credit Card Processing Text Message Reminders Live Operator Patient Portal Card on File Payment Plans
- 31. Self-Pay Success 31 93M Self-pay reminder notifications sent out in 2013 $82M collected on our Patient Portal in 2015 YTD
- 32. Thank You
Editor's Notes
- Welcome and introduction
- Introduce self and role at athena. Introduce athenaResearch and all the data being collected and how it is analyzed Looked into data and identified practices that were better and we asked them Used athenaNet to tell us who did this really well and what their best practices were so we can teach you goal is to study top performers across our national network of 67,000 providers, isolate what it is that they do differently from average practices, and disseminate the resulting insights across our client base. athenahealth is a learning network dedicated to the success of our clients. In our conversations with high-performing provider groups, we have identified ten best practices for improving patient collections. The particular combination of practices worth considering will vary based on a group’s individual circumstances and overall patient collections performance. Some will provide outsized returns on minimal changes to practice operations; others will benefit those whose performance most lags that of their peers.
- Data gathered from across athenahealth’s network shows that 18%, essentially almost a quarter, of our median provider’s revenue comes from patient obligations. However, as health care costs continue to rise, patients are having to pay for more and more of these costs out of pocket.
- Because these costs are rising so dramatically, health care plans are moving to share increased costs with their members in the form of higher premiums and larger copayments and deductibles. In addition, the growth of unemployment, self-employment, and consumer-directed health care plans (CDHPs) means that more individuals are shouldering the burden of health care costs themselves. Since 2010, we’ve seen a 75% increase in the number of Americans with high-deductible health plans. That number is expected to skyrocket by 2018, when more employers will only offer high- deductible plans rather than pay a 40% tax for high-cost plans (known as “the Cadillac tax”). ----- Meeting Notes (11/5/15 14:28) ----- kaiser foundation released 2015 number of people with HDHP
- We have also seen a rapid increase in commercial patient obligations. Since 2010, these obligations (for visits with some patient financial responsibility) have increased by 23% for visits to athenahealth providers, and we expect this trend to continue, if not accelerate, in the coming years.
- Even providers who have not yet seen a drop in their incomes no doubt sense that financial concerns increasingly affect their relationships with patients. Patients may filter medical advice through an economic lens, weighing perceived health benefits against unexpected and often unknowable financial obligations. High-deductible plans leave many patients to shoulder steep expenses; the resulting stress (and those decisions to avoid costly care) could have significant negative effects on patient outcomes. Therefore, providers have an opportunity not just to improve their own financial performance, but also to ensure that patients understand and can fulfill their financial obligations. Clinicians are increasingly serving not just as partners in care but also as navigators of the complex reality of paying for health care services. ----- Meeting Notes (11/5/15 14:28) ----- unable to pay deductables exceeds liquid assest
- Data drawn from across athenaNet shows that in 2014 alone, all obligations in the total cost of what the patient owes for non-preventative care visits have increased across the board. What it boils down to is a that practices can no longer assume their collections efforts will involve a consistent stream of co-pays and small balances. Instead, they are now larger balances that patients simply cannot afford to pay. This “new normal” of large balances of medical services standing uncollected from patients leaves clinical practices somewhat stranded. Take out 2011-2013 make in straight corners
- From research done at athenahealth, 40% of providers fail to collect $25,350 or more from their patients each year. We have also found that across athenahealth, there is significant variation across specialties in patient collections by practice, specialty, and physician.
- Primary care providers, for example, have minimal unpaid patient obligations, likely from of the lower average cost of the services they provide, the greater proportion of visits with no patient obligation, and the value of an ongoing patient-provider relationship in establishing payment expectations and providing opportunities to collect at the time of service. High-cost specialties, like orthopedics and cardiology, both have greater average unpaid obligations and greater variation in collection performance.
- Data collected around the physical size of clinical practices shows intriguing data. Medium-sized groups have worse average patient collection rates than smaller and larger groups. Compared to large medical groups and health systems, these groups typically provide high-cost specialty services, more so than small practices, and they often struggle to maintain consistently high performance across multiple practice sites.
- The connection between a provider and their patients is highly personal so having the conversation about payments can be tricky. Clinical practices are not built to run on principles of a retail store yet certain aspects of running the business now seem very closely related. In light of navigating this difficult balance between medical care and financial compensation, many practices dismiss self-pay practices in favor of the sacred doctor-patient relationship.
- Practices may rely on discrete “in house” methods or instead outsource the whole of patient billing altogether but each policy has difficulties and great opportunities for improvement. Given existing trends in the insurance market, the amount of money individual patients will have to pay for their health care is only likely to increase, as will the challenge of collecting those obligations. Practice administrators, front office managers, and billing directors must focus on building their organization’s capabilities. Even moderate effort from large to small groups can yield hundreds of thousands of dollars in incremental revenue.
- There are four tactics your practice should employ but before you start, it is important to know where you stand. To begin you should calculate your patient pay yield.
- Targeted staff training that emphasizes the importance of patient collections and helps front-line staff members effectively communicate payment expectations. Front office and billing leaders develop a thorough training curriculum that covers conversations about patient financial obligations, use of athena collection tools, and the importance of patient collections.
- Premier’s co-pay collection rates show that a rigorous approach to training can drive real financial improvements. As the graph below shows, Premier’s average co-pay collection rate has improved by about 50%, from 31% in February (when Premier’s leaders resolved to reengineer their training curriculum) to 48% in June. The improvement has been especially pronounced among low-performing staff members, who are now collecting co-pays about three times as frequently as they were at the beginning of 2015.
- Assessment IMPACT: High Training programs are effective but only if well organized, consistently delivered, and taken seriously by management and staff. Training is most effective when combined with staff audits, which determine whether staff members are following through on their training. EFFORT: High A systematic training program requires effort but is foundational to an effective overall effort. athena provides materials to help practices create scripting and teach staff about various athenaCollector tools.
- OKC OB/GYN is a 20-provider practice with an overall yield on patient obligations of 79%, due in large part to a consistent emphasis on collecting prior balances at the time of service. The practice administrator reviews all patient accounts two days in advance of appointments and calls patients with outstanding balances over $100. Patients are asked to settle their outstanding balances at or before their visits. The practice administrator leaves notes in patient records for those she hasn’t spoken with, and check-in staff will have those patients speak with her in person before seeing a physician. OKC offers payment plans to accommodate patients with large balances who are unable to pay in full during their visits. However, the practice will reschedule patients with significant balances who are unwilling to pay at the time of service and decline to work with the practice on payment plan arrangement (with the permission of providers; exceptions are of course made for patients with urgent medical needs). OKC’s focus on notifying patients of outstanding balances before their visits and working with them to determine appropriate payment options has had significant impact on their overall collections. As the graph below shows, OKC OB/GYN (shown in purple, compared with similar-sized providers in green) has an extremely high overall patient collection rate and is near the top of this cohort in the frequency with which outstanding balances are collect at the time of service—OKC asks for payment most of the time, and they also succeed in collecting most of the time.
- Assessment IMPACT: High Practices perform better if they have a game plan for patients with outstanding balances. This approach is most effective if patients with relatively high balances are called before they visit to establish appropriate expectations proactively. EFFORT: Moderate Reviewing patients with outstanding balances before their visit requires time and effort. However, these efforts likely save time and reduce front office anxiety around interacting with patients.
- FWC’s increased use of card-on-file was driven largely by a single practice that improved very quickly, filing a patient’s credit card for between 50% and 70% of visits. This rapid progress shows that patients are receptive to a strong expectation or requirement for providing a card on file, and that practice staff can readily adapt their collections approach to emphasize credit card collection. athenaCollector’s card-on-file feature increases collections. For encounters without a card on file, FWC collects about 70% of patient obligations; for visits with a credit card contract, the group collects 81%. The five FWC care centers with the greatest utilization are performing better still, collecting more than 88% of patient obligations for visits with Card on File agreements.
- Assessment IMPACT: High Most practices should attempt to collect credit card information, regardless of a patient’s balance. The success of credit card collection in the urgent care segment indicates that this approach is viable if expectations are communicated to patients and executed by staff. EFFORT: Moderate Although there are few workflow changes required to accept credit cards on file, some patients may have concerns about the security of their credit card information or the uncertainty of committing to payment of an unknown balance, and some front office staff members may be reluctant to advocate for card-on-file contracts.
- Within eight months of implementing Phreesia, Keystone saw significant improvements in a number of patient registration and financial metrics:
- Assessment IMPACT: Moderate Digital check-in tools have improved registration completeness, credit card payments, co-pay collection, and outstanding balance collection, but they do not fully replace other efforts to educate patients about their obligations and work with patients with large balances. Practices considering digital check-in devices should focus on how the resulting reduction in staff time spent on registration can improve collections. EFFORT: Moderate athena’s Marketplace partners are fully integrated with athenaCollector, which simplifies set-up and integration, but practices will nonetheless need to choose a partner and implement a new service. Beyond the technology requirements, workflow changes are minimal.
- Today Summit collects one-third of patient revenue via the portal. The magnitude and speed of this shift to online payments surprised Summit’s Director of Clinical Process Management, who believes it is largely a result of the convenience of online payments. Summit also encouraged portal payments through a call campaign focused on patients with outstanding balances.
- Assessment IMPACT: Moderate Practices are strongly advised to maximize their portal adoption rates in order to increase patient loyalty, better engage patients in their care, and lower administrative expenses. Portal adoption should also have a beneficial impact on patient collections if this functionality is clearly communicated to patients. EFFORT: Low As long as a practice is pursuing portal adoption more broadly, encouraging patients to pay via the portal is relatively simple and does not disrupt the check-out process.
- We also provide you the tools you need to make it easier to collect on patient obligations and to ensure your practice runs efficiently. payment plan
- Combining all our strategies, we are able to drive results for our clients.