'Everybody learns, everybody teaches' in collaborative on upfront collections

NAHAM initiative result of calls for best practice data

A collaborative on upfront collections sponsored by the National Association for Healthcare Access Management (NAHAM) turned out to be "a good experiment" that allowed participants to learn from their counterparts in other hospitals while also working alone in their own organizations, says Karen McKinley, RN, MBA, CHAM, vice president of the division of clinical effectiveness at Geisinger Health System in Hershey, PA.

The average increase in upfront collections among participating hospitals was about 30% during the 15-month time frame for the collaborative, which began in October 2003 and ended in December 2004.

The initiative came out of ongoing calls for best practice and benchmarking information from NAHAM members, adds Pete Kraus, CHAM, business analyst, patient accounts services at Emory University Hospital in Atlanta. McKinley, Kraus, and Nancy Farrington, of Main Line Health System in Berwyn, PA, served as faculty for the collaborative.

The project — suggested by McKinley in the wake of a large clinical collaborative in which Geisinger participated — provided that information without the more costly investment of research and resources required by the benchmarking process, Kraus adds.

While "benchmarking" has been defined as "the process of determining who sets the standard, and what that standard is," a collaborative can be described as a "joint effort among multiple organizations that share resources and information," according to materials prepared by organizers of the NAHAM collaborative.

See collaborative model)

To facilitate the project, a web site was created where the participating hospitals could chart their progress, Kraus explains. Each facility set its own goals, and three measures were taken: total upfront dollars collected, self-pay charges collected upfront, and emergency department (ED) dollars collected upfront.

Participants recorded on the graphs the percentage of the goal attained during each reporting period.

"Once a month, [participants would] call and get together, and update the graphs on the web site," Kraus says. "It was a collaborative on at least two levels — in the facility itself and in the individual department."

IHI model used

As part of her work in clinical effectiveness at Geisinger, notes McKinley, a former access director and a longtime NAHAM member, she has been involved with the Institute for Healthcare Improvement (IHI) for about eight years.

"What we talked about doing was trying to find a way to do improvement work, but also getting some measures that could be used to benchmark," she says. "We used the IHI collaborative model, which is very public."

The role of the collaborative faculty began with educating participants about improvement work by giving them the tools to help establish an aim or goal for what they wanted to achieve, McKinley explains. "Once they knew the target or goal, they could go about doing the work to improve.

"It starts by building a team of people to talk about it," she says. "You do brainstorming around areas to improve, then focus in one or more areas, make small changes, and measure them."

One of the key steps in the process, McKinley says, is doing what the IHI model terms "tests of change."

Once a team has set its aim, established its membership, and developed measures to determine whether a change leads to an improvement, the next step is to test a change in the real work setting, according to the IHI.

The Plan-Do-Study-Act (PDSA) cycle, she says, is shorthand for testing a change — by planning it, trying it, observing the results, and acting on what is learned.

The reasons to test changes, according to the IHI web site, are:

  • to increase your belief that the change will result in improvement.
  • to decide which of several proposed changes will lead to the desired improvement.
  • to evaluate how much improvement can be expected from the change.
  • to decide whether the proposed change will work in the actual environment of interest.
  • to decide which combinations of changes will have the desired effects on the important measures of quality.
  • to evaluate costs, social impact, and side effects from a proposed change.
  • to minimize resistance upon implementation.

'Just ask'

After the first eight weeks of the collaborative, Mt. Graham Medical Center, a 59-bed hospital in Safford, AZ, went from collecting $1,700 a month to collecting $7,800, says Candi Garcia, supervisor of admissions. (See Charts.)

"We found in this collaborative that the most important thing was to just ask for the money," she adds. "A lot of our employees weren't asking. Once we pushed it, and they got it as a mindset, we increased 78% over eight weeks and probably stayed at about that. Once we got in the groove, it just worked for us."

One of the first conclusions reached by the group as a whole was that, no matter what, a hospital had to have its administration behind the collections effort, Garcia notes. "That's where it has to start, and we did have that 100%.

"The first thing we did was go to our chief financial officer," she recalls. "We told him about the collaborative, and got strong support. Then we set up a meeting with our patient accounting [staff] and our whole administration."

To make sure access staff were fully prepared for the collections initiative, Garcia says, arrangements were made for a senior admitter to work one on one with each employee.

"He took each admitter and gave them three to four hours," she says. "He started at the beginning and went through the entire process and all the insurance codes. He made sure everybody was asking the patient the questions the right way."

In addition, Garcia says, every Mt. Graham admitter spent about two hours with the patient accounting staff, stressing the importance of getting every piece of information correct and explaining what happens if there is a mistake in the patient's address, for example, or if the insurance policy number is wrong.

Because Mt. Graham is a small hospital in a rural community, it didn't have many self-pay patients, compared to the other participating facilities, she adds. "Even though only 5% of our community is self-pay patients, we wanted to come up with a way to help them also, so [it was decided] that if they could pay the bill upfront, they would get a 30% discount."

That discount is not just for ED charges, she notes, but includes all hospital departments.

As part of the effort to obtain copays and deductibles at the time of service, Garcia says, her staff went over the hospital's most common insurances and made lists of the required payments. "We made phone calls and found out what [the copay/deductible] was in the emergency department, and what it was for labs and X-rays. We made cheat sheets and gave them to every department, so they would know what to collect."

The process was simpler for Mt. Graham than it would be for most other hospitals, she notes, because there are a few main employers in the small town of Safford that account for most of the patients' insurances.

That was one of a number of ideas discussed among participants in the monthly conference calls, Garcia says.

During these monthly sessions, which lasted between 45 minutes and an hour, she adds, "all of us would tap into the NAHAM web site and get into our charts. We would look and see how each [facility] had improved or was down. If someone's [collections were] down, we would talk about it with them, and about how to get them up."

Another brainstorm that came out of the collaborative phone conferences was conducting morning "huddles," she says. "The idea was to have one team leader on each shift talk with [other registrars] about the goals for the day, how much they would try to collect."

That didn't work for Mt. Graham, Garcia says, because there are only about six or seven admitters on duty in the hospital on any given day. They aren't in a position to "huddle" because they are spread among the ED, the main admitting area, and radiology, she notes.

Goals, incentives tailored to each facility

Some of the organizations, including Mt. Graham, provided rewards and recognition for registrars who met certain collection goals, Garcia notes. These included "dress-down" days, gift certificates, parties, and lunch, as well as celebrating high achievers at staff meetings and in hospital newsletters, she says.

One of the things Garcia did — and shared with other members of the collaborative — was to take about half her admitting employees to a seminar in Phoenix called "Get Your Ask in Gear," she adds. "Once I mentioned that at the [NAHAM] conference, I had everybody wanting to know what it was."

Other hospitals, Garcia says, got good results from putting a credit card machine and/or a cash collection box in the ED to make it easier for patients to make a payment.

While the key measures of the collaborative were selected by a planning group, she points out, participants refined those measures and set specific goals appropriate for their individual hospitals. That could mean focusing on, or excluding, a particular department or category of patient.

For example, Mt. Graham measured total dollars collected upfront, self-pay dollars collected upfront, and ED dollars collected upfront, she says, while Girard Medical Center and St. Joseph Hospital, both located in Philadelphia, only measured the first two components.

The two Philadelphia hospitals, each about three times the size of Mt. Graham and in busy, urban settings, "have so many people coming in and out, so many self-pay patients, that they didn't have the time and manpower to do the third [measurement]," Garcia adds.

Despite such differences among hospitals, the group's experience was that the collaborative approach can work for all, she notes. "You approach it differently, and make goals that [are realistic] for your facility. "Our money collected upfront is nothing compared to those hospitals, but look where we are located. It just depends on the area you are in."

Julie Johnson, CHAM, director of revenue cycle management and HIPAA privacy officer at Mt. Graham, says she has observed that chief financial officers who ask "What's in it for us?" when it comes to benchmarking clearly see the benefits of a collaborative.

"With this, each hospital saw improvement, something that happened for its own benefit," she adds. "[Participants] were mentoring each other on things that worked and those that didn't work."

As a NAHAM board member, Johnson says, she was eager to volunteer Garcia and Mt. Graham to be part of the collections collaborative — and did so again when a project on medical records and patient safety was started in 2005.

"I see it as a benefit for our facility and a growing opportunity for leadership," she says. "It's important for us to participate when there is an opportunity."