Reducing Preventive Flips to Diagnostic— A Holistic Approach to Improving the Financial Experience for Members



 

Peter Gazanian; Erin Bilvado, MBA

https://doi.org/10.7812/TPP/19-039-31

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Colorado, Georgia, Hawaii, Mid-Atlantic States, Northern California, Northwest, Southern California, Washington, Program Office

Background: Rising medical costs are in the national spotlight and have been a growing concern for our members. Kaiser Permanente (KP) surveys show 50% of members are surprised by bills they receive. Contact centers report more than 20% of service billing complaints are a result of visits scheduled as preventive, then billed as diagnostic. Members are reaching out for help, even to the office of Bernard J Tyson. Improving our members’ financial experience is of utmost importance as we transform internal operations to uphold the KP mission of providing affordable health care.
Methods: The study targeted preventive encounters that commonly result in surprise diagnostic charges and member complaints. Member complaints are identified through the financial service recovery program, which provides a stopgap by empowering contact center representatives to resolve issues and, if appropriate, adjust charges within set guardrails. On the basis of the documented reasons for complaints, cross-functional teams, including Patient Financial Services, Permanente Medical Groups, Revenue Cycle, and Benefits, review accounts and conduct data analysis to determine key root causes and options for resolution of the issues. The initial focus is reducing negative experiences and member complaints around preventive examinations.
Results: Analysis of complaints received for scheduled preventive visits billed as diagnostic revealed 70% were indeed preventive examinations. In the KP California Regions, 3.4 million preventive examinations occurred in 2018 with 617,000 visits (18%) resulting in additional patient cost share. Of the 617,000 visits, 16% resulted in members reaching out to the contact center with 9% resolved through an adjustment of charges and 1% through a formal grievance. Analysis of these member complaints revealed 2 major scenarios: 1) cases where preventive services were documented and system alignment could potentially resolve the issue, and 2) cases where nonpreventive services were present.
Discussion: Solutions to the complex issues in our organization and industry will not be determined or designed while staying within the silos of our departments or functions. We must work together—holistically and iteratively—with shared accountability to achieve a truly integrated care and coverage experience that has our members at the center. As next steps, priority opportunities are being identified and driven to address the preventive examination issue under executive leadership across Patient Financial Services, Permanente Medical Groups, Revenue Cycle, and Benefits. Additional improvement efforts are in the queue, including vision and laboratory services.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


 

Promising Methods for Improving Quality Through the Faster Spread of Best Practices

Abstracts2019TableThese abstracts reflect the critical importance of a forum for presenting promising quality efforts. Meetings focused on quality improvement, such as those hosted by the Institute for Healthcare Improvement, the American Medical Group Association, and many other organizations, represent a relatively small percentage of all scientific medical meetings. The publication of abstracts from a dedicated quality event such as the Kaiser Permanente National Quality Conference allows those inside and outside of Kaiser Permanente to learn about new and potentially unfamiliar practices that could improve care.

BEHAVIORAL HEALTH

The Impact of an Innovative Patient-Practitioner Therapeutic Community on the Management of Chronic Pain
Karen Peters, PhD; Barbara Gawehn, RN, LAc

Zero Suicide Implementation
Jacqueline Ryan, MPH; Pavan Somusetty, MD; Han Liang, MD; Eli Pahl, LCSW, CADC III;

Implementation and Dissemination of Cognitive Behavioral Therapy for Depression in Kaiser Permanente Hawaii: Impact and Lessons Learned
Bradley E Karlin, PhD, ABPP; Gregory K Brown, PhD; Shari Jager-Hyman, PhD; Kelly L Green, PhD; Michi Wong, PhD; Diane S Lee, LCSW, CSAC; Andrew Bertagnolli, PhD; Thekla Brumder Ross, PsyD

Lessons from Implementation of Behavioral Health Integration in Kaiser Permanente Washington
Rebecca Parrish, MSW; Ryan M Caldeiro, MD; Amy Lee, MPH

WELL BEING

100,000 Quitters and Counting—Striving for a Tobacco-Free Generation
Renee Fogelberg, MD; Mariko Muzzio, MPH; Annida Brunato; Karin Dove, MPH; Debora Sawyer, MD; Christopher Lee, MHSA

The POWER Journey of a Mid-Atlantic Permanente Medical Group Physician (Pursuit of Wellness, Engagement, and Resilience through Social Support)
Susan Leggett-Johnson, MD, MBA; Gene Gincherman, MD; Mary Zmuda, MPH

Malama Ola—Taking Care of Your Well-Being
Sharin Sakurai Burton, MD, PhD; Casey Akana, RN; Sandra Tompkins, RN; Kristy Yoshikawa; Julia Gregory, RN; Hyewon Jun, MD; Mae Lynne Swoboda, MPH; Courtney Farris, MA, MINTee; John Banagan, MPH, CHES; Eric Kamimura, DPT; Steve Nakata, COTA, MBA; Derek Chee, DPT; Quyen Nguyen, PhD; Jennifer Davis, RD; Kimberly Oshita, RD; Merle Miura-Akamine, MD; Kaipo Pau, MD; John Sheehan, MD

Increasing Team Safety and Response to the Threatening Member
Bradley Christie, PhD; Laura Ketterman, HEM

CARE MANAGEMENT

Continuing Care Quality Management: Practice, Performance, Proof
Peter Khang, MD, MPH, FAAFP; Jennifer Cortez; Christine Jordan, LCSW; Artem Aghourian, MBA

The Hepatitis C Care Cascade: Increasing Comprehensive Screening and Diagnosis
M Cabell Jonas, PhD; Michael Horberg, MD; Jacquelyn Redd, MD; Dana Sloane, MD; Eric Wollins, MD; Carla Rodriguez, PhD; Bernadette Loftus, MD

Measuring Diagnostic Error: A Review of Patient Complaints
Michael H Kanter, MD; Lawrence D Lurvey, MD; Kerry C Litman, MD; Ronald K Loo, MD; William Strull, MD; Mimi Hugh, MPH, MA; Maverick Au

No Place Like Home: Surgical Home Recovery
Michele Knox, MD; Wendy Rabinov, MD; Michael Nwynn, MD; Ashima Garg, MD, PhD; James Chang, MD; Claire Spanbock, MBA, RN, CNOR; Edgar Servais; Bijal Shah, MHSA; Tamar Fendel, MPH; Annie Davis, MPH; Joeffrey Hatton, MBA

Mid-Atlantic States Chronic Heart Failure Program
Farzaneh Sabi, MD; Machelle Behzadi, MHA; Betty Rice; Jessica Kane; Blair Van-Horn

Patient-Centered Management for Chronic Disease—A Model Applied to Parkinson Disease Care in Southern California
Jason Cheves, MSBA; Steve Cedrone, MBA; Todd Sachs, MD; Kathy Kigerl, RN, MN

Coordinated Regionwide Care Management Intervention for Patient with Chronic Obstructive Pulmonary Disease at Risk of Acute Exacerbation Reduces Hospital Days
Richard Mularski, MD, MSHS, MCR; Sanja Uskokovic, MS, PMP; David M Mosen, PhD; Bryan L Skalberg, MS; Achikam Haim, PhD; Marianne C Turley, PhD; Nancy L Lee, RPh; Wui-Leong Koh, MD

Decreasing Sleepless Nights for Patients and Practitioners by Fast Tracking Patients with Diagnostic Images Highly Suspicious for Cancer
Rischl Alindogan, BSN; Brian Doerning, MD; Robert Lin, MD; Jamie Difiori, MD; Harold Chow, MD; James Carter, RPA; Cynthia Payne, PhD

Combining Minimally Invasive Thoracic Surgery Techniques and a Multidisciplinary Care Model Leads to Superior Outcomes
Brian Timm, PA-C; Christopher Mutrie, MD; Piotr Starosta, PA-C; Julie Faulk, PA-C; German Collazo, PA-C; Yong Shin, MD; William Shely, MD; Thomas Lampros, MD; David Tse, MD

Patient-Centered Redesign of Total Joint Replacement Care: Achieving the Quadruple Aim
Kate Koplan MD, MPH, FACP, CPPS; Violeta Rabrenovich, MHA, CHIE

HIV/AIDS: A 30-Year History of Care Delivery
Patricia L Philbin, RN; Karen Lewis Smith, MHA; Susan McDonald, RN, MSN; Kathy Brown MD, FACP, AAHIVS; Dan Kent, PharmD

Enhancing Dispositions from the Emergency Department—the Northern California Journey to Care for Increasingly Complex Populations
Rayne Soriano PhD, RN; Vivian Reyes, MD; Jo-Ann Griffin, RN

Mid-Atlantic States Hospital Patient Day Rate Reduction
Farzaneh Sabi, MD; Pam Galley, MAOL; Claire Pagano, MHA; Blair Van-Horn

Preventing “Silent Droppers”: Standardizing Interventions to Prevent Lung Function Decline in Patients with Cystic Fibrosis
Jennifer Bass, MD; Adrienne Aldredge, MS; Ashley Addington; Richard Cohen, MD; Megan Danish; Susan Mikkelsen, MD; Kay Pasquesi; Kimberly Rondeau; Megan Wackford; Eric Walter, MD

EQUITY

Igniting an Inclusive Movement—Utilizing ILEaD (Inclusively Leading Through Equity and Diversity)
Laura Long, MBA; Susan Terrill

Addressing Disparities in Health with Motivational Interviewing
Deborah Baker, PhD; Hyewon Jun, MD, MPH; Dee Keyser; Peggy Latare, MD

The Community Action Poverty Simulation
Lakiesha C Tidwell; Madalynne Wilkes-Grundy, MD; Shari G Chevez, MD; Anna Khachikyan

MEDICATION MANAGEMENT

Reducing Opiate Use in Children and Teens: A Strategic Approach to a National Challenge
Anna Grosz, MD

Impact of Medication Reconciliation Programs on Reducing Readmission Rate and Enhancing Medication Safety During Transitions of Care
Alfonso Becerra, PharmD; Donald Yee, RPh; Karen Cham, PharmD; Sheireen Huang, PharmD; Shubhi Nagrani, PharmD; Adenola Akilo, PharmD; Karina Briones, PharmD; Kelvin Chan, PharmD; Carolyn Woo, PharmD; Chad Friday, RPh

PATIENT ENGAGEMENT

Human-Centered Design at Kaiser Permanente: A Creative Approach to Problem Solving
Jeff Hall; Connor Shea; Estee Neuwirth, PhD

Meeting Members’ Wishes in the Last Year of Life: A Journey Toward Concordance in Southern California
David Glass; PhD Michael Kanter, MD; Paul Minardi, MD; Susan Wang, MD

Using Insights from End-of-Life Care Survey to Drive Improvement of Care at the End of Life
Margaret C Wang, PhD, MPH; Diane Brown, PhD, RN, FNAHQ, FAAN; Peter S Khang, MD; Ruma Kumar, MD

Reducing Preventive Flips to Diagnostic—A Holistic Approach to Improving the Financial Experience for Members
Peter Gazanian; Erin Bilvado, MBA

TOTAL HEALTH

How Healthy Is My Community—Designing a Measurement System for Leaders and Implementers
Pamela M Schwartz, MPH; Elisa Wong, MPH; Allen D Cheadle, PhD; John M Vu, MPH

If You Want to Know How Mrs Smith is Doing, Ask Her! KP’s Improved Medicare Total Health/Social Risk Assessment
Tracy Lippard, MD, FACP; Carole Gardner, MD, AGSF; Matt Stiefel, MPA, MS; Ranu Pandey, MHA; Juliana Oronos, MPH

Bridging Barriers to Care Access and Delivery: The Automation of Nonemergent Transportation in Kaiser Permanente Mid-Atlantic States
Kyle M Heidenberger; Rachel E Hill; Melissa Baldwin, MS, MBA; Jason C McCarthy, PharmD, MBA

Addressing Social Needs: Organizational Learnings and Connecting with Our Communities
Sarita A Mohanty, MD, MPH, MBA; John F Steiner, MD, MPH; Nicole Friedman, MS; Briar Ertz-Berger, MD, MPH

TEAMS

The Kaiser Permanente Northwest Ventricular Assist Device Program
Barbara Amos, RN, MSN, CNS; Timothy Jacobson, MD; Yong Shin, MD; Ryan Morrissey, MD; Siobhan Gray, MD; Pamela Montes, RN, MSN; Allison Lipnick, LCSW

In-Basket Management: Empowering Nurses to be First Responders for Patient Messages, Providing The Right Care at The Right Time
Dones M Trojillo, MSN, RN; Maia M Patel, MD, ScM

The Implementation of High-Reliability Organization Model for the Environmental Services Department at Santa Clara Medical Center
Eric Williams, MHSA; Kari Frank, MS; Marc Smith, MHA

Building A Virtual Nursing Team: Implementation of the Advance Alert Monitor
Laure E Lisk, RN, MS, CPHQ, CPHRM; Elizabeth Scruth, RN, PhD, MPH, CCNS, CCRN, FCCM; Vanessa Martinez, MSN, MPH, RN; Bronwyn Cox, MSN, RN; Kris Wilson, RN, MSN, CPHQ

Improving Quality and Safety Together: Reducing Primary Cesareans Perinatal Core Measure Collaborative
Lyn Yasumura, MD; Cheri Lowre, MD; Leslie Casper, MD; Marianna Volodarskiy, RN, MSN, NE-BC

TECHNOLOGY

Leveraging Technology to Improve Appropriate Imaging Studies: There’s an App for That!
Peter Huynh, MD; Paymann Moin, MD; Michael Flores; Pamela Galvan; Steven Ethington

Using Human-Centered Design to Expand Telehealth Into the Hospital and Continuum
Reema Shah MPH; Estee Neuwirth, PhD; Lan Nguyen; Carissa Lim; George Go, MD; Tamara Hillstrom; Dan Huynh, MD; Margaret Pierce; Colette Lundahl; David Miura; Lisa Arellanes

Home Health Virtual Complexivist Physician Program: Leveraging Increased Scope of Care at a Crucial Time
Alicia Ahn, MD; Sandra Barton, MD; Binitha X Surendran, MBA, MS

Improving Patient Safety Via Information Transparency and Performance-Improvement Infrastructure
Asia Plahar, MS, RN; Kathy Ricossa, MS, RN

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