The best deals in cars and care may be found at the end of the month.

I have been a physician for almost 20 years, and my income has been going down- a lot.  With the rising cost of insurance premiums this might seem counter intuitive to many Americans.  However, there is an explanation, albeit a perverse one, that helps explain this disconnect.

There is no cost of care.

Unlike most markets, there is no fixed price for care.  What you pay depends on whether you have insurance, the terms of your insurance and  the rate that has been negotiated on your behalf. Different insurers negotiate different rates for the same service.  For instance, a CT scan or blood work may be paid at a factor that is 2 or 3 times more than another insurer.  In part this has to do with other services the insurer needs.   For example, access to specialty coverage may be offered by a care delivery network to an insurance company in exchange for higher reimbursement on other services.

Rather than bill everyone at the lowest negotiated rate, not surprisingly hospitals tend to bill at the highest one.  Everyone gets caught in the same net. The hospital don't want to miss out on the highest possible reimbursement for a particular procedure.  Unfortunately, the person least able to pay, the uninsured patient, gets billed for the largest amount as well.


Imagine if Walmart's everyday low price depended on your ability to pay?

   My salary is made up of a mix of payers- payment for the same CT scan can vary widely.  Lately, my practice has seen increasing volumes, some decrease in insurance reimbursement/case, and a large increase in the ability (or willingness) to pay for services by the uninsured.  Based on the mix (insured and uninsured) we now collect something like 28 cents for every dollar billed.  Imagine if Walmart collected 28 cents on the every dollar?  I am betting prices would go up.  This  isn't good for me, and it isn't good for the consumer.  

Given the large uninsured population of my downtown hospital, some analysts predict Obamacare may actually improve this 28% reimbursement.  This presumes reimbursement for each case will decline, but  the portion of charity cases will decline more- everyone will be insured.  However, with the same size pie, this will have short term issues for other segments of the market, and is not sustainable. 

Fair care at a fair price- the end of the month, cash may be king.

Like many things in American healthcare, the billing system is byzantine, kluged together with no real thought or roadmap.  Until we deal with this fundamental disorganization, I expect the general mistrust between patients, physicians and insurers to rise.  Insurance premiums are currently viewed as a surrogate for physician salaries.  This is simply not true.   Medical costs have gone to such extremes that the number of Americans with no insurance is rapidly expanding and now make up an increasing pool of reimbursement.  Ultimately, we have to pay for care if we want to have services moving forward.  I would far prefer to get paid a fair price by all patients.   When you are sick and most in need, adding financial pressures fundamentally seems wrong.  

Ideally each bill would be somehow be "patient centric."   However, today's financial tools do not allow this level of service.  What I can tell you is that hospitals and providers have a discounted price, one that is much closer to their cost of business.  Asking for a negotiated rate, particularly for the uninsured/self pay, will likely to be met with interest.  I am not sure what this rate is but it is something less than 100% and more than 28%.  And sadly, like car dealers, from what I have been told, the best deals may be found at the end of the month.

RAP Lesson Learned #3: The Power of Team

Rhonda Barcus, Program Specialist

Lately, I have shared a little about two of the lessons I learned from conducting RAP interviews with hospital leaders. We conduct these interviews in order to gather outcome data from hospitals who have participated in an onsite consultation through Rural Hospital Performance Improvement (RHPI) Project. The first lesson was about the “power of a conversation” and the second concerned the power of “meeting people where they are.” The third lesson involves the rich abundance created from Team.

When I contact an administrator to schedule time to talk about the RHPI project, I encourage other leadership members to join the conversation as well. The really wise administrator usually makes sure the leadership team is included in the conversaton! The richness of the RAP interview increases exponentially when the team is present. This isn’t because there are just more people to talk; it’s because each person brings a unique view and experience which more clearly reflects the many facets of the project. One person might be more data-minded while another can speak more easily of the impact of a project on the patient and another might discuss the impact of a project on the employee. The really smart administrator knows there isn’t just one “right” point of view but instead, many pieces reflecting different aspects that give a more complete picture.

In his book, The 7 Habits of Highly Effective People, Stephen Covey describes the importance in Habit 6 for the need to “synergize.” This is defined as “creative cooperation.” I once worked with a manager who was a master at this concept. While many managers tend to hire employees that are similar in style and personality to his or her own, this leader would purposelyseek out new employees who brought a different view. He knew that strength was found in a team, and a diverse one at that, and that to try to maintain a narrow way of thinking, where everyone agreed on everything, would only weaken the ability of the team to build this “creative cooperation.” The key wasn’t to develop a team with only one viewpoint but to choose team members with different views AND who also had the ability to cooperate.

This power of team is one of the really important lessons learned from RAP. The first time I called an administrator at the time of our meeting and he had included a number of his leadership team, I was actually taken aback. In the two years of interviews though, I’ve discovered it’s almost predictive. The interview that includes the whole team is usually the one that results in some of the richest outcomes data. It is as if the culture is “we are all in this together” from project beginning (planning) to end (outcomes) and every single person has an important piece to contribute.

RAP Lesson Learned #2: The Power of Meeting People Where They Are

Rhonda Barcus, Program Specialist

Last time, I shared a little about the first lesson I learned from RAP(Recommendation Adoption Process), the process we use to gather outcome data from hospitals who have participated in an onsite project through Rural Hospital Performance Improvement (RHPI) Project. That first lesson was about the power and impact of just having a conversation with someone. The second lesson concerns the power of “meeting people where they are.”

 

RAP involves asking lots of questions about how the hospital implemented the consultant’s recommendations and how that affected measurable outcomes. This is a conversation which could easily put someone “on guard”, feeling like they have to justify their actions, or sometimes, inaction. When we created the RAPprocess, we based it loosely on an organizational development model called Appreciative Inquiry (AI). AI focuses on discovering what is going well and the strengths and assets and seeks to create more of what already “is.” This approach is very unlike the medical model or problem solving model which focuses on the deficits, illness, or problems. 

The first question in the RAP process is “Tell me what is going well.” As the administrator (or sometimes entire leadership team) begins talking about their successes, my next question is “and what else?” We continue with this line of questioning until they can no longer name another success. The power of this approach is that it often leads to the interviewees saying, “Wow, I didn’t realize we had accomplished so much!” 

The next part of the conversation is geared towards next steps or discovering what hasn’t gone well. Instead of asking about the problems, the focus is on what the hospital would be doing to create the best possible outcomes from this project. The question then might be, “If you could imagine the best possible outcomes for this project, what would you all be doing more of or differently?” This very naturally leads into a discussion about recommendations not implemented or setbacks to the project. Done in this way, the conversation is not defensive or negative because in the spirit of AI, it focuses on “what could be.” It is a subtle, but very effective way to get at the barriers or sometimes resistance but does so in a way that is motivating to moving forward.

The other critical piece of RAP that reinforces “meeting people where they are” is the way the stage is set from the beginning of the conversation. We have discovered that most projects take one to two years to implement. I always begin a conversation by letting the hospital know that. There is often a sigh of relief heard through the phone followed by, “Thank goodness, we were worried you would think we hadn’t done enough.” It is amazing the incredible amount of work most hospitals have already done on a project but they expect to be told that they should be finished in nine months. Thorough and thoughtful implementation takes time but is more likely to lead to a sustainable project with lasting results.

Next time, RAP Lesson Learned #3: The Power of Team.