Affordability/Money - Color

Like casts and splints, X-rays are a routine part of patient care in the Orthopedics department at South Bay Medical Center. Unfortunately, missed copays for those X-rays were becoming common as well.

“Patients will get their X-rays done at the end of the visit—and then walk out without realizing that they owe a copay,” says Christopher Kresch, department administrator for Orthopedics and the team’s management co-sponsor. At other times, patients will unexpectedly need X-rays during their visit, and because the orders are placed during the exam, the charges are not captured during check-in.

So the team borrowed a practice from the Los Angeles Medical Center and developed a check-in sheet that shows, at a glance, if a patient has an outstanding X-ray copay. The team also adjusted its workflow to ensure that a staff member walks the patient to the front desk to pay the fee by the end of the visit.

Here’s how the process works:

The receptionist gives the check-in sheet to each patient at the start of the visit. As patients travel through the clinic to receive care, the form goes with them, enabling staff to conduct “warm hand-offs” by writing notes to each other about the patient’s care. When a copay is owed, the last person to interact with the patient escorts him or her to the receptionist.

“It helped us in a lot of different ways, much more than we thought it would,” says Naomi Guerrero, an Orthopedic technician and SEIU-UHW member who is the team’s union co-lead. “Now we can’t live without it.”

Side benefits

After introducing the check-in sheet, the team saw almost immediate improvement in copay collection. In July 2014, missing copays—known as the total collected variance—totaled $2,166. Between August and November 2014, the total collected variance fell to just $533, a whopping 75 percent improvement. Those numbers are holding steady. The department is averaging a 50 percent increase in copay collections through third quarter 2015.

Besides boosting copay collection, the check-in sheet helped the team improve patient care. Unexpected benefits include:

• Keeping patients informed of delays and expected wait times improved patient satisfaction scores. Positive patient responses about staff communication on the Ambulatory Satisfaction Questionnaire (ASQ) rose from 48.67 between August and December 2013 to 57.74 for the same time frame in 2014. The regional target is 54.5.
• Direct booking—when a staff member makes the first appointment for a patient referred to a specialty department—soared from 38 percent of all referrals in July 2014 to 68 percent by November 2014, exceeding the regional goal of 40 percent.

• An increased percentage of patients who receive bone density screenings. In 2013, 89.7 percent of eligible patients received the screening; that rose to 91.9 percent in 2014. The regional target is 85 percent.

Finding the right solution

Before adopting the check-in sheet, the team sought input from a group of staff members and physicians in the department. Incorporating their voices gave them ownership of the project and enabled the team to create a check-in sheet that worked for everyone. For example, physicians rejected an early draft featuring a detailed checklist in favor of blank space to write their orders. And receptionists vetoed an early color-coding system as “too confusing.”

“We learned a lot as we went through our tests of change,” says Guerrero. “We learned there are changes that don’t work out.”

Adoption takes time

Once team members were happy with the check-in sheet, they spread it to the rest of the department. Convincing their peers to consistently use the check-in sheet took time.

“The medical assistants were resistant because they saw the check-in sheet as an extra step,” says UBT representative Zackry Ellis, a physician assistant and member of UNAC/UHCP.

Some providers also were hesitant to use the form, preferring to speak with staff. That’s when the team turned to Anthony Leone, MD, the department’s physician chief, for help.

“He helped us sway others to try it out,” Guerrero says.

Once staff members understood the benefits of the check-in sheet—enhanced copay collection, improved workflow and better patient care—they all began to use it consistently.

Patients are reaping the benefits of the new form, too.

“Because of the check-in sheet, we’re communicating more with our members,” says UBT representative Esmeralda Montes, a lead medical assistant and SEIU-UHW member. “They feel happy and cared for, and that’s our ultimate goal.”

The next step for UBTs—a step they are being challenged to take by top management and union leadership—is to make the leap from successful individual team projects to a systemic effort to implement proven practices throughout the organization.

Meantime, remember another bottom line: High-performing teams score more favorably on People Pulse questions related to efficiency and cost reduction, and high-performing teams are more likely to take on affordability projects.

Working with your colleagues to become a high-performing team is a sure step toward reducing waste and improving affordability. Being high performing will help Kaiser Permanente continue to assist and care for families and will help us ensure everyone has affordable health care.

Here are some ways that unit-based teams can help keep Kaiser Permanente affordable.

1: Build business literacy

The more teams know about the business of health care in general and of their own departments specifically, the better equipped they are to find savings. To that end, LMP’s Education and Training department is rolling out an economic literacy program in the coming year. Meantime, teams in both California regions have been using a curriculum developed by a multidisciplinary team in Northern California. The five-part course has caused some trepidation, since in the last two trainings teams go through their department’s budget line by line—but that’s exactly what gives the training its juice.

At the Fremont Medical Center in Northern California, the OR team took the training and instantly started looking for ways to save money. Co-leads Yolanda Gho, Operating Room nurse manager, and surgical tech Gus Garcia, an SEIU UHW steward, talk about the training, its benefits and how it inspired their team to do better. (For more on this team, click the Peer Advice link in the resources box.)

2: Be supply savvy

Teams that take the time to make a comprehensive assessment of their supplies—tracking inventory use, tidying up storage areas, streamlining ordering and so on—can save tens of thousands of dollars with hardly any pain.

For instance, the scientists in the Immunology department at Southern California’s regional reference lab use expensive chemicals, called reagents, to test whether patients have serious infections such as hepatitis and HIV. Cleaning out and meticulously organizing the department’s huge walk-in refrigerators allowed the team to order larger quantities of reagents at one time. Since employees have to test a sample from each shipment, fewer shipments mean fewer tests—saving staff time and expensive reagent. The work, which also means the team needs fewer rush shipments, is saving $50,000 a year.

Another example comes from the Head and Neck Surgery UBT at the Franklin Medical Office in Colorado, which kept trying small tests of change until it found a reliable way to prevent the disappearance of expensive surgical tools. Contracting with outside individuals or companies often is more expensive than having the same thing done in-house. “In-sourcing” can range from health education centers in Northern California using KP-produced pamphlets instead of costlier items from an outside company, saving $64,000, to the Ohio region opening new micro-clinics so patients in the suburbs can see KP physicians instead of non-Permanente providers. (For more on this team, click "Losing Streak Ends for UBT" in the resources box.)

3: Bring it home

Contracting with outside individuals or companies often is more expensive than having the same thing done in-house. “In-sourcing” can range from health education centers in Northern California using KP-produced pamphlets instead of costlier items from an outside company, saving $64,000, to the Ohio region opening new micro-clinics so patients in the suburbs can see KP physicians instead of non-Permanente providers. (For more on the Ohio region's work, click on "Micro-Clinics, Macro-Partnership" in the resources box.)

4: Collect the money we’re owed

Health care in general and Kaiser Permanente in particular is filled with mission-driven people. But KP can’t sustain its mission if we don’t collect the money we’re owed.

In Colorado, the Medicare Risk Business Services UBT members spotted and fixed a technical problem with incomplete physician signatures on patient charts, which allowed them to bring in more than $10 million in Medicare revenue that otherwise never would have been collected. In Santa Rosa, Calif., the patient services representatives in the Emergency Room analyzed data and did some role playing with one another to reduce discomfort about asking for co-payments.

Figuring out issues like these takes tenacity, as the Patient Financial Services team in the Mid-Atlantic States discovered when it set out to fix problems with workers’ compensation claims. (For more on this team, click "Closing a Financial Gap" in the resources box.)

Jeff and Sara Simmons describe themselves as a “pretty average, middle-class” family living in a Northern California suburb with their sons. “We live a Lego life with two boys,” laughs Sara, describing her toy-strewn living room.

But eight years ago, Sara was diagnosed with Type 1 diabetes, thrusting her into a routine of checking her insulin, monitoring her diet—and paying steep bills for medication and medical equipment. Recently, 7-year-old Owen also was diagnosed with the disease. And the family has to plan for the possibility that 5-year-old Griffin might be diagnosed with it as well.   

Even though the family has medical insurance with Kaiser Permanente, the new bills related to Owen’s care overwhelmed them. They applied for help from one of KP’s medical assistance programs, which helped tide them over until they could get a handle on their new reality.

In the months since, the Simmonses have made some tough choices—deciding, for example, to sell their home and move to an area with a lower cost of living. But Jeff, a manager in a major corporation, worries about how families with lower incomes and fewer health care benefits than his would have fared under similar circumstances.

“How do they do this?” he wonders. “How are they surviving all of these curveballs?”

Health care is “absolutely not” affordable for most people, he says—then adds, “Everybody should have affordable health care. Period.”

A difficult equation

The passage of the Patient Protection and Affordable Care Act in 2010 was a major step toward ensuring all Americans have access to health care. As provisions of that act take effect in 2014, Kaiser Permanente will have an extraordinary opportunity to further our historic mission of providing affordable, high-quality health care to working families. But with the opportunity comes a difficult financial reality. Because these incoming new members may not have had access to health care in the past, they may be costly to treat—and federal reimbursements may be on the low side. In addition, the federal government has recently cut the rates for Medicare reimbursements, which typically have provided about one-third of KP’s revenue.

So Kaiser Permanente and unit-based teams face the challenge of treating more—and perhaps sicker—patients with fewer resources while maintaining and increasing the quality of care. Now more than ever, allocating our resources wisely is vitally important.

Frugal power

It’s easy to see how departments with multimillion-dollar budgets play a role in keeping KP affordable. For example, National Facility Services kept an eye on potential energy savings when a new data center was built and saved about $450,000 in electricity costs in 2010 and earned a $300,000 incentive from the local utility company. Another example: KP saved $26 million in 2010 alone by buying safer and more environmentally friendly industrial chemicals. And a redesign of the way KP deploys computer workstations saved $12 million as of August 2011.

But unit-based teams have just as big a role to play, even if most don’t control huge budgets. The fact that there are more than 3,500 UBTs across the organization means savings can add up dramatically.

Some teams are saving “light green dollars,” focusing on efforts that indirectly improve the financial picture. That might be boosting service and quality, which helps us get new members and retain the ones we have, or improving patient safety, which reduces a variety of expenses, including costly hospital readmissions.

Others are tackling “dark green dollars,” direct savings that improve the bottom line right away. In fact, efficiency and non-payroll cost reduction is the fastest-growing category of projects for teams, according to an analysis of UBT Tracker data.

Is your team looking for new ways to save light or dark green dollars—or in need of ideas to get started saving? Read Four Ways to Save.