Putting access together again

Longheld notions re-examined

(Editor’s note: ScrippsHealth in San Diego is in the midst of a massive redesign of its expense departments and front-end processes. Here’s the latest in a series of occasional reports on the project.)

As ScrippsHealth continues its revenue cycle redesign, part of an overarching project called Scripps Team Achieving Results (STAR), longheld perceptions about the way business should be done are being scrutinized and, in some cases, discarded, says Jack Duffy, FHFMA, corporate director of patient financial services.

"It is really, really neat to take this whole thing apart and put it back together again," Duffy says. "Historically, we have created a situation that is not manageable."

Having consultants from Southfield, MI-based Superior Consultant Holdings Corp. as part of the team "doesn’t allow you to take your ball and go home," he points out, something that often happens when different departments are asked to justify expenses and redesign their processes.

Bigger goal requires bolder reductions

What typically happens when an organization undertakes such a project is that it results in an incremental improvement in productivity of 5% to 10%, Duffy says. "That usually means a layoff and letting the survivors do the work."

With the goal Scripps has in mind — 30% improvement in productivity — those incremental changes just aren’t enough, he adds. The plan is to reduce labor and service expenses by one-third in patient access, medical records, and the business office, Duffy explains. That effort, if carried by the labor component alone, would mean eliminating 100 of the 400 full-time equivalent positions in those three areas, he adds.

"We found out we had embedded some expensive business practices in our hospitals," Duffy says. "The most expensive was because we fell in love with patient-focused care.’ In the cold light of day, access becomes hugely expensive when commingled with nursing secretary or other departmental duties."

In fact, he adds, Scripps has found that by combining positions in an effort to decentralize services, it pays a premium of 200% to 300% over what a focused department would cost. Meanwhile, he points out, "patients never commented that bedside administrative services were better than sliced bread. Some like it; some consider it an intrusion."

The Scripps redesign will affect access services in three primary ways, Duffy explains:

1. There will be a return to discrete departments. "The blended version, combining nursing secretary and other job descriptions with access, is not effective for access," he says. "There are significant issues with training. The [secondary access] employees fell behind the training curve because the managers had trouble releasing them for even brief training sessions." That meant the hospital had to back up those point-of-service employees with back-end rework, Duffy adds, which meant eligibility and authorization information often was obtained late.

When Scripps looked at the annual systemwide overhead associated with moving its 800,000 to 900,000 patients from the first point of contact through the conclusion of the billing process, it found the cost to be about $27.5 million, he says. "Only $18 million is in the centralized [patient financial services] budget, so that means $9.5 million is outside the direct control and supervision of finance."

An estimated 500 to 800 people split their time between access and other duties in their individual departments and spend as few as 45 minutes a day on access, Duffy points out. "When we track denials [of reimbursement], we draw some pretty startling correlations between those accounts and these part-time access people."

That strongly speaks to the wisdom of having regionalized specialty areas for registration — one for a campus, one for a building, or maybe one for a pod of departments — all of which are staffed by full-time employees, he says.

2. Scripps will extract all the precare administrative services possible and move them to a call center, or "customer contact center." "We don’t believe it’s possible to hit best practice production levels when you commingle a physical work queue with a telephone work queue," Duffy says. "The telephone work queue will never get done and so will have to be reworked. That means a big chunk of this [registration] stuff goes all the way into billing with embedded errors. If you don’t segregate the telephone work, you’ll never reach the potential of electronic billing, HIPAA [Health Insurance Portability and Accountability Act] standardization, etc."

With this in mind, Scripps plans a customer contact center that it estimates will ultimately employee 35 people and perform some 1 million preadmissions annually, he says.

3. Scripps will re-evaluate whether there will be a limited form of centralized registration to accommodate walk-in traffic. Bedside registration will be an option, Duffy notes, but for the most part will not be necessary because the registration will have been handled in advance. Scripps also is considering the possibility of having electronic kiosks that will enable patients in ancillary departments to interact with an access employee at a central facility, he adds.

The patient accounts receivable cycle (PARC) that Duffy is charged with improving is one of three areas under the STAR project, which began in April 2000, he points out. Two other executive sponsors oversee clinical nurse processing and case management. A reduction of $6.6 million is expected in the budget for patient access, medical records, and the business office, from $18 million to $11.4 million, he says. "When you look at the outside departments [also involved in access services], the reduction is even more — from $27 million to $11.4 million."

Scripps estimates half of those savings will be achieved between October 2000 and September 2001, and the other half in the first six months of 2002, he says. "It’s a neat, quite enlightening process. We look at tools and technology, but not until there is agreement on work processes. Work groups [on that subject] report to the hospital administrators every few weeks."

Issues to consider include whether a function will be managed by a single department or co-managed with dotted-line reporting, he says. "We put all the turf issues out front. Does registration report to the hospital administrator, or does it report to the corporate finance department? What we decided, in that case, is that because of all the training involved, it needs to be part of the central finance department."

Reserved as the sole responsibility of the hospital administrators, however, is the design and implementation of central scheduling, Duffy notes.

"We had two very long, tense meetings where we cleared the deck of any lingering issues regarding management structure, accountability, and process ownership, so we have a very solid foundation," he explains. "All the administrators [from hospitals in the Scripps system] are required to attend the meetings. It’s very empowering. Without this, you’re building on quicksand."