Customer Experience Meets the Healthcare Journey

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  • 1. WHITE PAPER CUSTOMER EXPERIENCE MEETS THE HEALTHCARE JOURNEY HOW TO WIN TODAYS HEALTHCARE CUSTOMER Executive SummaryTABLE OF CONTENTS Over the past decade multiple forces have caused the healthcare market in AmericaExecutive Summary .................. 1 to transition from that of managed care and capitation to integrated delivery1. Task Routing and WorkloadDistribution .............................. 5 (integration of health insurance with provider systems) to a vision in which2. Resource Management ...... 11 providers compete to improve care quality and control costs, and consumers choose the best providers. The only thing that is likely to remain constant is change,3. Facilities Management ....... 15 particularly as provisions of the Patient Protection and Affordable Care Act take4. Revenue CycleManagement.......................... 18 effect over the next few years aimed at improving healthcare outcomes and5. Compliance......................... 20 streamlining the delivery of health care.Summary ................................ 23 At the most fundamental level there are three perspectives on the discussion thatSolution Components ............. 24 need to be understood and accounted for if any meaningful discussion is to be held,Conclusion .............................. 24 here represented as the Three Ps of Healthcare which translates to Patient,About Genesys ....................... 24 Provider and Payor. Patient Payor Provider F IGURE 1: THREE P S OF H EALTHCARE
  • 2. WHITE PAPER WHITE PAPER Customer Experience Meets the Healthcare Journey / Page 2 of 25You can see in this diagram that there are interaction points between all three; thetriangle in the center represents offerings that are integrated. Although each have acritical role to play in order to understand contact and medical history, the goal is tofind the right balance that delivers optimal patient health at a reasonable cost. In afully integrated environment the triangle in Figure 1 we would find a modelsolution operating as one contact system that provides the following for eachstakeholder: Patients: Front-end solution, with the insurer or medical group, to view claims, bills, contact history, medical history, e-mail the doctor, look-up symptoms, and so on. Provider: Task Routing, facilities management, revenue cycle management. Payor (Insurer vs. Patient): o Insurer: system to pull Healthcare Effectiveness Data and Information Set (HEDIS), claims, costs reports, charts for case management, etc. o Patient: billing, collection, back office financials, etc.The Centers for Medicare and Medicaid Services (CMS) and Health & HumanServices (HHS) are especially keen on this idea of making sure their money goes along way, and they are asking insurers and providers to integrate systems, processesand the overall healthcare system so that focus is delivery to the patient. Theirmessage has always been: Dont make healthcare difficult for the consumer, period!In lieu of this level of integration, the focus should be on the Provider deliverysystem. One way to understand how this plays out is to examine the patienthealthcare journey.Patient Healthcare JourneyJust as no two patients are the same, no two healthcare journeys are the same. Inorder to provide some framework, consider two common scenarios. The firstscenario involves the initial task every patient has of finding and visiting a primarycare physician for Routine/Preventative care.
  • 3. WHITE PAPER WHITE PAPER Customer Experience Meets the Healthcare Journey / Page 3 of 25F IGURE 2: R OUTINE/P REVENTATIVE C ARE J OURNEYThe patient must first contact the physician referral service in order to find anappropriate provider. Then the patient must contact the providers office toschedule an appointment. After visiting the physician, the account needs to besettled. This could be covered by insurance, in which case a co-pay will likely needto be paid by the patient. In some situations the entire cost may be theresponsibility of the patient.Consider the level of coordination between The Three Ps for something as simple asa routine doctor visit. Apart from the actual visit, think of the legions of peopleworking behind the scenes to schedule the appointment, code services, file a claim,determine benefit eligibility, pay the bill and keep tabs on the status!The second scenario is for Acute/Emergency needs that involve wellness centers,physicians, hospitals and urgent care centers for the patient. This process is morecomplex as it can involve activities prior to the visit to identify financialresponsibility, and after the visit to speed recovery and minimize avoidable hospitalreadmissions.
  • 4. WHITE PAPER WHITE PAPER Customer Experience Meets the Healthcare Journey / Page 4 of 25F IGURE 3: ACUTE/E MERGENCY C ARE J OURNEYDuring a visit to the physician it is determined that it will be necessary to schedule aprocedure at the hospital. The provider works with the patient and the insurer toascertain financial responsibility. The patient visits the hospital, has the procedureperformed, and is discharged. A bill is sent to the insurer, and any unpaid balance isbilled to the patient.And just like with the Routine/Preventative example, the Acute/Emergencysituation relies on an even greater level of coordination between The Three Ps.There are lots of moving parts in both examples, yet each stakeholder needs toprotect their interest while providing for the patients optimal health. Areas inneed of examination include: 1. Task Routing and Workload Distribution 2. Resource Management 3. Facilities Management 4. Revenue Cycle Management 5. ComplianceThe remainder of this document explores the Provider delivery system in greaterdetail.
  • 5. WHITE PAPER WHITE PAPER Customer Experience Meets the Healthcare Journey / Page 5 of 251. Task Routing and Workload DistributionMultiple interactions happen between all three parties as well as ancillaryparticipants and suppliers such as outpatient clinics, pharmacies and suppliers ofdurable medical equipment. If the contact is not face-to-face, theres a good chancethat the interaction will be handled by a contact center, acting as the intermediaryfor various business units.F IGURE 4: P ATIENT I NTERACTIONSThe primary source of work in most contact centers comes from inbound voice callsthat are handled by an Automated Call Director (ACD). In some cases there mayalso be outbound call activity that is either direct dial or handled by an outbounddialer. There could also be a range of digital channels available to facilitate email,chat, SMS and video interactions.Sometimes the interaction is short - simply answering a question; other times, itmay be an involved process spread out over time. Regardless of the interaction
  • 6. WHITE PAPER WHITE PAPER Customer Experience Meets the Healthcare Journey / Page 6 of 25channel used, the goal is to connect the patient with the right resource to getinformation or assistance.F IGURE 5: I NTERACTION C HANNELSInteraction ChannelsPatients have become accustomed to interacting with most companies via inboundand outbound voice for decades, as well as fax for sending and receiving printedforms and documents. More recent digital channels include: E-Mail for discussing symptoms, recommending a course of action and sending prescriptions, especially when the patient is out-of-town; submitting electronic documents such as out-of-network claims. Chat and Video for interacting with nurse advice teams. SMS/MMS for sending appointment reminders, receiving images from patients