CarePayment Program Hospital Outcomes: Results from Semi-Structured Interviews with Hospital Staff

Abstract

The research described in this article was supported by a grant from the W.K. Kellogg Foundation.

Introduction: Although the Affordable Care Act (ACA) has resulted in lower medical debt rates among Americans, bad debt remains a significant problem for U.S. hospitals. A number of companies offer patient financing programs that may help ameliorate hospitals’ bad debt-related challenges, including CarePayment (CP), which offers a zero interest line of credit to patients at participating hospitals. We undertook an exploratory study of CP outcomes that is, to our knowledge, the first independent outcome evaluation of a patient financing mechanism in the U.S. One purpose of the study was to investigate hospital-level outcomes through qualitative interviews with hospital staff.

Methods: We conducted semi-structured, in-person interviews with staff who worked directly with the CP program at a purposive sample of hospitals. Priority was given to hospitals serving low-income populations, and to creating a sample of hospitals of different sizes and offering CP for different time-periods. The interview questions addressed hospital context, interviewees’ experience with CP, and CP outcomes. Interviews were audio-recorded and transcribed. The online platform Dedoose was used to facilitate coding and qualitative analysis. Analytic memos on outcomes of focus were developed and discussed among the study team.

Results: Five hospitals participated in interviews, with 23 staff interviewed in total. Across the hospitals, bad debt was reported to have either gone down or leveled off due to CP. All five hospitals reported that having CP manage a bill payment plan was beneficial. Four reported not having the staff, skills, and/or systems to efficiently manage the internal payment plans they had prior to CP. Contrary to our expectation, no interviewee felt that changes in bad debt rates or other savings associated with CP have had a direct impact on hospital provision of charity care or other community programming. Finally, at least one interviewee at each hospital expressed the view that CP helps to give the hospital a competitive advantage because of patient satisfaction with the program. Interviewees offered stories exemplifying patient satisfaction, and cited few complaints and repeated use of CP as further evidence.

Discussion: The findings provide preliminary qualitative evidence of positive outcomes for most indicators that were examined. Two hospitals’ experiences of observing higher-than-expected rates of returned accounts due to non-payment by CP patients underscore the need for ongoing analysis of collections performance in light of revenue cycle objectives, in order to ensure the best possible revenue outcomes through the program. Limitations that should be taken into consideration in interpreting the study findings include CP’s involvement in selection of and outreach to potential participant sites, and the possibility of social desirability bias influencing the interviewees’ responses. Steps were taken to reduce both potential sources of bias.

Conclusion: Bad debt and payment collection challenges are likely to remain important problems for U.S. hospitals. External patient financing options, such as CP, have the potential to reduce bad debt and improve payment collection efficiency and patient satisfaction. Hospital administrators might consider the promise of such programs for benefitting both the bottom line and patient care.