Increasingly, imaging leaders are observing changes in patients’ behavior. Schedulers are fielding questions about the cost of procedures, while front-office staff, technologists, and even radiologists are being called upon to deliver greater levels of service—spending more time with patients, alleviating concerns, and explaining procedures. These changes point to the arrival of a trend that has been discussed periodically over the past 20 years or so: health-care consumerism. Outpatient imaging, in particular, is primed to feel the effects. Procedures are non-urgent, allowing ample time to select from the multiple providers operating in many markets. Significant price variation, especially between hospital-based and freestanding facilities, also makes outpatient imaging susceptible to the pressures of consumerism. A number of market forces have combined to bring about consumer behavior in patients; five of these forces are particularly important. First, cost shifting: Heightened cost shifting has made patients increasingly price sensitive. Patients are now responsible for a larger portion of their health costs than they have been in years past. The percentage of US workers with high-deductible health-care plans tripled from 2006 to 2010,1 with 30% now responsible for at least the first $1,000 of costs (and up to almost $6,000, for family coverage). Adding this cost shifting to the existence of about 50 million people who are uninsured in the United States makes it clear that patients have a strong interest in seeking care from the provider offering the greatest value. This has led many to shop around for health-care services. Second, patient steering: Payors have long been aware of the huge price differences among imaging services, and they have recently intensified their efforts to steer patients toward lower-cost imaging providers. These efforts don’t end with steering alone. Some insurers have begun to offer patients cash incentives (typically $50 to $200) when they select lower-cost providers for particular services.
Two large payors, Anthem Blue Cross Blue Shield and Harvard Pilgrim Health Care, have deployed these types of programs, encouraging patients to go online or call a toll-free number and compare prices for certain ambulatory procedures. In fact, Harvard Pilgrim Health Care’s Save-On program even pays $10 to patients who simply make the call, not even requiring the patient to select the lower-cost provider (Table 1). Third, social media: Social-media platforms—Facebook, Twitter, and especially the consumer-review site Yelp—all allow patients to shop virtually for providers. Increasingly, these sites have become places where patients share information on health-care providers, writing reviews about experiences both positive and negative.
Survey² data underscore the spread of this trend: a quarter of adults are using social media to post information about their health-care experiences, while 42% access these reviews (Figure 1). These numbers show the importance of ensuring that every patient interaction is a positive one. Reviews are shared instantaneously with millions of people, affecting providers’ online reputations. Fourth, patient-satisfaction scores: Beyond reputation, patients’ perceptions of their experiences with particular providers are now tied to reimbursement. While CMS started administering the Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey in 2006, on October 1, 2012, its results became part of the measures included in value-based purchasing, tying patient satisfaction directly to payment. The 27-question HCAHPS survey is submitted to patients after discharge and asks about their experiences: How responsive was the staff? Would the patient recommend the hospital? While these categories focus on the inpatient experience, ambulatory experiences are likely to become part of the system. Moreover, it also is probable that commercial insurers will follow the lead of CMS, introducing comparable pay-for-performance initiatives that encompass patient satisfaction. Programs that focus now on improving the outpatient experience will be well prepared when reimbursement hinges on performance. Fifth, choice of provider: The patient’s choice of provider is staunchly protected within accountable-care organizations (ACOs), underscoring the importance of the patient experience. Many of these models of care delivery are not the traditional, restrictive HMOs of the past, which limited the patient’s choice of provider. In fact, Medicare’s Shared Savings Program, rapidly taking hold across the country, allows individuals to choose their providers, placing the attributed ACO at financial risk for any services provided outside the network. By providing strong service, imaging programs can reduce the chance that patients will receive out-of-network care. Simplifying Patient Transactions Faced with all of these forces, many provider organizations have begun to take a hard look at current service delivery, scrutinizing operations and searching for ways to ensure that patients feel that they are getting the greatest value for their health-care dollars. While dramatic gestures can be effective, efforts will be futile if the basics aren’t mastered. The first step, for every imaging program, should be to remove obstacles to patient convenience. One aspect of convenience is self-service; many patients prefer to handle the administrative tasks associated with health care online. In fact, one survey3 showed that almost 80% of patients are more likely to select a provider with online services over one without them. Specifically, patients would like to preregister for appointments, get pre-procedure instructions, and have access to financial information (Figures 2 and 3).
Figure 2. Nearly 80% of patients would select a provider with online services over one without those services.3
Figure 3. Online preregistration is the most sought-after service, followed by access to preappointment instructions and the ability to view and pay bills.3
Despite the evidence that patients would benefit from greater online access to services, health-care providers have lagged well behind other industries in supplying such access. In 2008, the Advisory Board Co’s Imaging Performance Partnership (IPP) conducted an audit of 100 member websites and tabulated the percentage that offered a number of key services. Though most programs had sites, they were frequently missing key functions. Only 46% of programs actually provided directions to the imaging site, and 42% were providing exam-preparation information—two very basic capabilities. Performance on a more advanced service, processing online appointment requests, was worse, with only 9% of program websites providing that function. To gauge progress since 2008, the IPP conducted the audit again, calculating the percentage of programs with websites that offered the services originally identified. While notable improvements have occurred—100% of programs have imaging websites that list services and contact information—many programs continue to lag. Only 76% are providing directions to the imaging center. While a greater number of imaging programs are offering this service, websites without this information are missing a great service opportunity. Giving directions online prevents patients from having to search elsewhere, eliminating an extra step.
Figure 4. Imaging-provider members of the Advisory Board’s Imaging Performance Partnership offering online information/services.
Further, fewer than half of sites provide exam-preparation information (a service that benefits both patients and imaging staff). When the information is made available online, employees field fewer pre-procedure phone calls and questions, allowing them to concentrate on other aspects of their roles. While the percentage of programs allowing online appointment requests has doubled, only 17% of websites provide that service (Figure 4). Hospitals Versus IDTFs As part of this analysis, the IPP also audited the websites of a number of IDTFs. While hospitals’ and IDTFs’ websites are comparable for basic offerings, hospitals lag (by a wide margin) for more advanced services. Of IDTFs, 93% offer exam-preparation information online, compared with only 30% of hospital imaging programs. Bill payment, which 51% of patients prefer to conduct online, is facilitated by 60% of IDTFs and 23% of hospitals. IDTF websites also include information and services that work to build an online community among patients; 90% of sites offer information about radiologists, 83% provide a forum for patient feedback, and 87% provide education and news. These percentages greatly exceed those for hospital websites (33%, 10%, and 43%, respectively). Taken together, the data show that the IDTF cohort, already lower in its pricing, is also making it easier for patients to obtain an imaging exam—an appealing combination for the price-sensitive consumer/patient (Table 2).
There are, however, some hospital-based programs that have advanced past the majority’s level and are offering extensive online services. Many progressive imaging programs have tackled scheduling first, allowing patients to request an appointment (or even self-schedule) online. For self-scheduling, the website typically lists available appointment slots by modality, and the patient clicks on the most convenient slot. He or she then completes a scheduling form with key details, and when the visit is confirmed, the patient is expected to send the referring physician’s imaging order, by fax or email, prior to the exam. Staff members frequently call the patient to confirm the appointment and obtain any further information that might be required prior to the exam. Online scheduling (and the convenience it offers to patients) must be balanced against the challenges of securing preauthorization from the payor in time for an appointment. Some programs build in a lag time, prohibiting patients from scheduling appointments fewer than 36 to 48 hours in advance. This lag allows ample time to secure preauthorization, avoiding the risk of lost revenue. While enhancing online services isn’t an easy task, doing so increases convenience for patients who are expecting ever-higher levels of service from their health-care providers. Enhancing online capabilities is one way that programs can simplify the process of obtaining an imaging exam for patients—and meet the growing consumer mandate.