The healthcare experience is often described as a journey. And while it is one on which the patient travels, an individual is not alone on the path. Providers and payers support and advance patients along their journeys, removing barriers, offering services, and providing clarity. To be effective in this role, payers and providers must follow journeys of their own, which operate in the background but are woven in and around the patient. Taken together, these interconnected pathways not only enable a positive patient experience, but also reduce overall care and operational costs, increase process efficiency, facilitate better clinical decision making, ensure regulatory compliance, and foster business growth and long-term financial viability.
This journey orientation framework can be found in other industries besides healthcare. The travel, retail, and financial services industries embrace this idea, choosing to align their operations and business processes around the customer. When healthcare organizations make a similar choice, they can more easily identify the friction points where the various journeys—clinical, financial, and encounter—cross and conflict. They can then apply the latest healthcare IT solutions to ease those friction points and create efficiency, value, and loyalty.
The end goal here is to make sure the different journeys are smooth and successful. The patient receives an exceptional clinical and financial experience; the provider gets the information it needs to deliver compliant, high-quality care and receive comprehensive and timely reimbursement; and the payer ensures its members receive excellent and responsive care while minimizing risk and taking costs out of the system. As organizations shift to this perspective and see improvement across the board, they will make meaningful progress toward a more responsive and resilient healthcare system.
The complex and multifaced patient journey can be divided into three main areas: the pre-visit, the visit, and the post-visit. The following sections explore the first of these stops, examining how the clinical, financial, and engagement pathways interact and interrelate during this time.
Laying the foundation for success
The pre-visit portion of the patient journey is a time when providers and payers are working to lessen any barriers to patient access, set the stage for accurate reimbursement, and limit downstream work. This requires streamlining and simplifying as many of the activities that occur during this timeframe as possible, including:
- Enabling self-service access for patients
- Verifying eligibility and authorizations
- Determining patient financial responsibility
- Securing patient payments upfront
- Accessing medical records quickly
By optimizing all these processes for the consumer, provider, and payer, each party can experience a stronger start to the healthcare journey.
Pre-visit activities should be highly attuned to the patient as a consumer. Individuals should be able to easily find a provider, understand what their financial responsibilities are going to be, schedule appointments, check their insurance coverage, and basically set themselves up for a successful visit. Within each of these steps, patients should feel like they do when receiving other services outside of healthcare. Processes should be easy and convenient, and patients should not have to spend cycles navigating complicated steps or tracking down critical information.
The financial journey taking place during this time involves making sure the patient is positioned so that the provider will receive accurate and timely reimbursement for services, whether that money is coming from payers or patients. The clinical journey requires physicians to have all the necessary clinical information to support high-quality care and demonstrate medical necessity.
Payers play a crucial role during this period as they work to make certain their benefit plans are followed, laying the groundwork for appropriate reimbursement. To achieve this objective, payers must present information about the insurance plan, provider network, and benefits in such a way that it’s clear, concise, and actionable. Armed with this information, patients can more easily find the care they need. In addition, providers, along with patients, can make sure they are primed for a smooth financial experience.
Establishing the right framework
To ensure the patient journey and all its interwoven clinical, financial, and encounter pathways unfold as they should, organizations need to have an infrastructure that streamlines and simplifies the various pathways. Such a framework must recognize the interdependencies present in the system and share comprehensive data from diverse stakeholders at key touchpoints. For example, as the front office financial staff at a hospital works to clear the patient and check that the appropriate benefits are in place, they need current and accurate data from the payer. At the same time, the patient requires precise information from the payer and provider to correctly estimate out-of-pocket responsibilities.
Solutions that connect to both payer and provider data sources can serve the relevant information to each party at the moment it’s needed. When these solutions interoperate and are powered by innovative technologies like APIs, artificial intelligence, natural language processing, and blockchain, they can further improve efficiency and precision, removing some of the manual aspects of cumbersome, error-prone processes. By bridging the gaps between the various journeys, these advanced solutions can optimize performance, helping all stakeholders travel along their paths more easily and reach their ideal destinations together.