Revenue Cycle Reimagined

In this episode, we talk with Valerie Barckhoff, MBA and learn about her work as a Principal in the Healthcare Advisory Practice at Windham Brannon. Valerie has deep experience in health care revenue cycle management and optimization and gives a tour-de-force overview of how artificial intelligence is being applied in this area right now and the potential uses in the future. Revenue cycle management is about far more than billing and collecting and Valerie’s insights reveal there’s a lot more “juice in the orange” when it comes to creating processes that are efficient and effective, pleasing to providers and patients and that can actually improve health outcomes. Valerie shares with us a seminal story from her teen years that sparked passion for the business of healthcare that has lasted over a 20-year career. Her pet peeve is laced with good advice and her sage wisdom is evident too.

Dr. Dave Levin:  Welcome to 4x4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I’m your host Dr. Dave Levin. Today I’m talking with Valerie Barckhoff. The principle in healthcare consultant practice at Windham Brannon. With more than 20 years of experience in health care revenue cycle and operations consulting, Valerie provides her clients with strategic, regulatory and operational consulting services. Those clients have included Safety Net Hospitals, Multi-hospital health systems, academic medical centers, community hospitals and life sciences companies. Valerie’s expertise is both broad and deep and includes key areas like population health readiness and implementation, financial transformation and regulatory support. Welcome to 4x4 Health Valerie.

Valerie Barckhoff: Thank you, I’m glad to be here.

Dave: We’re going to get through a series of four questions today and take about four minutes to answer each one. So, if you are ready, let’s get started.

Valerie: Sounds good.

Dave: So, first of all, tell us about yourself and your organization.

Valerie: Sure, I’ll tell you a little bit about Windham Brannon first and then I’ll tell you some more about my background but Windham Brannon is one of the oldest CPA firms in Atlanta. We provide audit tax and advisory services to our clients. We are definitely, heavily concentrated in the Georgia and the Southeast area but our clients go all across the country to New Hampshire, Vermont and all the way over California. So, we are not just isolated here in the Southeast and the healthcare is one of our largest industry statements that we serve. So, we do have a lot of clients. We serve a majority of the health systems and physician groups here in the Atlanta area. A little bit about my background is, I have over 20 years of healthcare experience which is kind of scary to say these days but you know, it is what it is and I’m one of those odd people who knew I wanted to work in the business of healthcare the minute I stepped foot at the University of Kentucky and consider myself blessed that they actually had an Undergraduate program that focused in healthcare administration and I even worked as an emergency room registration clerk, part-time throughout my education there at the University of Kentucky. I have worked in the revenue cycle all over the country. I’ve lived not only in Georgia but I lived in Wisconsin, Pennsylvania and the great state of Hawaii. So, I’ve been able to work with hospitals all over the United states and absolutely loved what I do.

Dave: Well, I always questioned the judgement if anyone who made it to Hawaii and came back.

Valerie: I know.

Dave: Well, we’ll set that aside for now. That’s fascinating, why did you have this passion from an early age, what was it that drew you to this particular calling?

Valerie: So, I tell everybody this story and I’ll try to keep it as brief as possible but when I was 16 years old, I got sick really, really fast and I grew up in a very small town in Kentucky. Remember knocking on my parents’ door around 10 p.m. and asking them how sick did I have to be to go to the hospital and they know me as the high pain tolerance stowed child, so they panicked very quickly. My father did what he thought was the right thing to do which was taking me to the nearest hospital but even at 16, I was asking him to drive into Lexington. At the same time that we were going through this, my parents who were public school teachers had just switched at an HMO plan. So, this is 1986, the hospital really didn’t know what to do when I showed up. So, the first thing that happened which I’ve looked. I’m taller was in effect at this time but they kept me in the emergency room and didn’t wanna see me because they didn’t have a doctor that was part of that HMO plan. So, the short story is, I had an appendicitis and it ended up rupturing in the waiting room while I was waiting for a physician to come in from Lexington. His name was Dr. Mooney, he was livid by the time he got there and they rushed me back, performed surgery but the nightmare didn’t stop there because the hospital had never seen an HMO plan, they didn’t know what to do with it, they sent my parents to collections and I just watched my family battle the insurance and collection process and felt very guilty about it but ended up resolving itself but it definitely triggered in me a fascination with the business of healthcare and not wanting other families to have to go through what we went through.

Dave: You there’s two things at that story that really jump out at me. The first is this kind of seminal experience that drew you in the healthcare and I meet so many people where that has been at some point something happened. Really in their life or maybe mid-career and they pivot and they come into healthcare because of the experience and then of course the other is particularly in a country like the United States the financial implications of getting sick and it’s so relevant to the debate that we’re having in this country about how we pay for care and I suppose we could devote an entire podcast to that and…, we want several, that’s right and we won’t get political here today but I think your story is, it’s a story that millions of people can probably tell, so good on you. So, it’s a broad area and then clearly as we heard in your intro, you are talented and you’ve done a lot of different sorts of things. What’s the most important or interesting thing that you’re working on these days?

Valerie: So, one of the most exciting things that we are working on is the creation of a digital employee at one of our clients. I tell people having been in this industry for 20 years, primarily as a consultant but I did spend a brief period of time where I actually ran the operations for two different health systems in Atlanta but when we look at a problem that a hospital presents with, whether it’s issues with their technology, their cashes is not where it needs to be, you know, and most hospitals operate on very skinny margins. We’re looking traditionally at three things, the people, process and technology and over the 20 years, we’ve seen advancements in technology and it might be better but it wasn’t dramatically different. So, about a year ago I was introduced to Digitize AI that I know you talked to Justin before and we started looking at those processes that are in the revenue cycle that are very predictable and very repeatable and we decided that we could apply artificial intelligence and robotic process automation to the business processes within the revenue cycle and this to me is that fourth lever that I can now pull for a client to actually help them and improve their effectiveness and their efficiencies related to revenue cycle processes and the majority of what happens in a revenue cycle when it comes to the billing and the follow up and even the pre-certification processes are very manual and are very predictable and repeatable. So, we are live with the digital employee in a pilot phase. It’s working exceptionally well. We’ve been able to take between 30% and 50% of the workload off of the staff and the goal is that we’ll be able to kind of upscale the staff to handle that more value-added work and take some of this more mundane work off of their plates. So, it’s exciting from that standpoint but it’s also exciting that this is one piece of technology that cannot only improve the effectiveness and the efficiencies which results in improvement in revenue but it can also reduce the cost of doing business too if we’re able to use machine learning to do that kind of work. So, I’m really excited about it. I tell people I’m kind of geeky excited over the possibilities and I’m excited to see how this plays out in terms of ROI and what does this mean of redesigning processes and can we truly have a better patient experience because we’re doing our jobs better the way we’re supposed to be doing them.

Dave: It is an exciting time. I’m geeky about this like you are and it feels to me like we’re at the beginning of the beginning.

Valerie: Right.

Dave: Potential for these things. I love problems like this or rather I love solutions like this for at least two reasons. One is, I think it’s a great window into how all of these things connect and the clinical care, the processes behind that, the operations and administration that are required in order to make it possible to do those things and then as you refer to it, I call it the iron triangle people process and technology that you almost always have to address, all three of those but the other thing that I love about solutions like this is, they really hit on all aspects of the Triple Aim. As you’ve alluded to, we’re automating a process that’s largely manual. That’s a win for the people involved. It should be a lower cost, it should be more efficient. As you pointed out, it should be pleasing both to patients and staff. As a former Clinician I would add, I think it improves care as well. My experience has been almost anything that reduces cycle times on healthcare improves clinical outcomes and just as I specifically discussed this, this notion of the patient that’s waiting for a treatment or to get a test so they can find the answer to what’s going on, that has real implications.

Valerie: It does and the administrative hopes that the payers put on the providers is definitely in my opinion sometimes intended to draw us out to help let us drop the ball. So, we talk about leveling the playing field with the payers and being able to be more effective and more efficient and one of the reasons we wanted to go with this digital employee pilot was we were having, at my client we were having significant issues with being able to just get the amount of work we had everyday and then patients would arrive and we wouldn’t have the pre-certain number. We would potentially have to delay care or we deliver the care in the hospital and physicians aren’t gonna get paid for it because we didn’t jumped through that administrative hoop. So, the main driver was to not delay care because of an administrative procedure anymore. So, that to me is gonna be the ultimate win is that we may still decide for physician convenience or patient convenience that the care needs to be delayed but we don’t want it to be because we administratively drop the ball. So, the really is the main driver. The net revenue, the cost efficiencies, that’s all gonna be just added value at the end of the day.

Dave: Yeah. Well, I don’t think there’s anything to apologize for there. I agree with the nuns, if there’s no margin, there’s no mission.

Valerie: Exactly.

Dave: And, healthcare in this country is a bad value, we pay way too much for what we get. So, I’m all in favour of addressing all of those sorts of things. Where put on your visionary hat and where do you see this going if you look out several years, we see what AI and robotics are doing to upend and transform other industries. Go out on a limb a little bit and tell us what you think has come in the next couple of years beyond this?

Valerie: I mean honestly, I see it continuing to grow. I think you’re gonna have a lot more players in other market. You’re gonna have people who enter the market, who may or may not be truly AI companies, they might be rebranding themselves. So, there’s that risk of make sure you’re partnering with the right vendor who truly is in that space and is truly machine learning and data scientist type organization but I truly believe having done this my whole career, the revenue cycle could be 60% to 70% run through artificial intelligence and that we could really have an impact on our effectiveness and our efficiency. So, I truly see a transformation and then I see it moving into other areas. You know, I was talking to some clients about the credentialing process that is very difficult to get through and could we use artificial intelligence for credentialing. So, there’s a lot things, even reporting. I see we have a lot of data now in healthcare but we haven’t translated that into useful information yet. We’re still learning how to do that and we have armies of very young smart talented MBAs doing that, could we use AI to help jumpstart that and not wait one week or two weeks to get that data synthesized, forced and pushed back out. So, I see that once we prove that AI works and it’s reliable that you’re gonna see this rapid advancement throughout this business processes in this healthcare sector.

Dave: Okay, and I love that optimistic picture of your painting but I also know you’re an experienced, seasoned veteran here. So, what’s keeping you awake at night about this, what are you worried about or what concerns you have right now about…?

Valerie: My biggest concern, well my biggest concern right now with what we’re doing because we’re interfacing with the payers is the payers trying to trip us up. Seems like anytime we try to find a way to become more effective and more efficient, they’re gonna find a way to trip us up. AI is gonna be a little bit more difficult to do but my concern is what is the payers’ response going to be when they realize that we have now leveled the playing field. They’re going to make their chess move with us and so trying to predict what that chess move is so that we can be ready for it is something that none of us really know what they’re going to do because it’s new for all of us. So, I think that keeps me awake at night and then the ability to take these entry-level staff and upskill them. I think we have a responsibility to the staff have been long-term employee’s people. The revenue cycle have been there 10-15-20 years. The organization will need to invest in training and tools for them, so that they can grow as we become more effective and more efficient. So, I don’t wanna see these people displaced. I actually want to see them advance in their careers as well and more hospitals aren’t prepared to address that and so that concerns me is that we’re gonna learn and rather than let go these lower waged employees and hire clinical staff to replace them, fewer of them, what can we do to make sure that these staff are being able to grow and learn and advance their careers as well. I’m very loyal to my people. So, I wanna make sure that we take care of them in this process as well.

Dave: Well, I got to respond to both of those. So, could not agree more with you about the people part of this and for my listeners who are smugly thinking that they are high level knowledge workers and they are shielded from this, no you’re not and I would argue that this is a conversation as a society. We need to be having much more broadly because AI and the robots are coming and it’s gonna displace many of us and we need to think about what that means as human beings and for the kind of culture we want to have as well as the economics. So, forgive me for getting on the soapbox there but…

Valerie: No, I agree.

Dave: I think your point is well-taken. I just think it’s much broader than people might realize right now.

Valerie: Exactly.

Dave: The other sort of the geopolitics of payers and providers and the rest and I definitely understand what you’re saying about the sort of technological warfare might be one way this plays out. Okay, so this is the part where I confess at one point, I was a health plan medical director. So, I have been both on the giving and the receiving end of no in my career. I hold out the hope of there may be a third way where through the use of AI we can really begin to get a better handle on who the outliners really are and focus on them and managing the outliners and everybody else has a gold card and they can just go about their business and I think there’s at least a possible scenario there, that’s a win for everyone. My own experience was that you are correct, there are times when payers will put these hurdles in place for less than admirable reasons but it’s also true that there are people that abuse the system and…

Valerie: Absolutely.

Dave: And, there is waste, fraud and abuse and all the rest of it. So, maybe there is a solution in there. Okay, so I want to remind you that this is a family show. So, please keep this PG-13 but what’s your pet peeve or favorite ramp these days?

Valerie: Well, my pet peeve, it seems to get with my industry and what I do for a living. So, a lot of people trivialize revenue cycle. They think we’re a diamond dozen, they think that anybody can do this work. What I can tell you is when I got first into this as a career, left being a registrar which is very complicated and of itself. I mean, those people have a very difficult jobs in terms of taking care of the patient, checking them in, making sure they’re doing everything right but then when I first got into this as a business career, you know, I sat in the room and I read the federal register and I really understood the rules and the regulations that surround the business of healthcare. It is not an easy thing to do. So, making sure that you’re hiring the right people, there are a lot of people who will say they know revenue cycle when they truly don’t and that’s when organizations get themselves into trouble. The thing I love about revenue cycle is I tell everybody, it’s the puzzle you’ll never solve because the situation is always changing, because the rules are gonna change, the payer rules, the regulatory environment that we live in, just the evolution of healthcare. So, it’s fun from that standpoint but I really don’t like it when people say, well, is it revenue cycle and commodity service? It’s not, it’s very difficult and understanding how those processes work with the technology is definitely something that I’m passionate about and I get a little sensitive when people call it a commodity.

Valerie: Yeah, you know, I couldn’t agree with you more and I gotta be careful because it’s clear which of the two of us is the expert on this discussion but as I’ve looked at revenue cycle, what I see is depending on how you define the scope, it can be very broad. I mean, and it can encompass again, here’s the amateur view but it’s everything from how you design and optimize your schedule to how the documentation is generated to reflect the actual service and there’s all kinds of efficiencies and opportunities there and then the sort of post-processing and all the way down to getting paid and going off to collections and whatever else you need to do and so, I’m with you. I think that, I suppose there’s a commodity service out there. You’re probably going to get a pretty basic and not a particularly thoughtful approach. There’s a lot of juice in that orange and many different ways I think to go after it. I wouldn’t try to do that myself. I’d go and find an expert like you but I’ve seen enough to know, hey, there’s a, for any given organization, there may be many points where the process can be improved. Does that make sense?

Valerie: Absolutely, yeah, absolutely.

Dave: I always tell my guests, please call BS on me…

Valerie: No, you’re spot on and the other thing, again I’ve done this long enough. Every organization is probably leaving a significant amount of money on the table. I mean it’s that complicated and that’s why I get excited about what I do because it is bringing more money into the health system, it’s not reducing expenses. So that, it’s the fun part of my job but every organization, I don’t care how great you are, there’s opportunity to get more.

Dave: Well, I think that’s right and as hard as people work in healthcare, it’s a shame to have money on the table.

Valerie: It is.

Dave: The eye-opener for me was, and again this is like totally novice stuff but the recognition that people were not just over coding, people under coding. Thinking that’s a defensive strategy when it’s not and not being recognized and rewarded for their work and then as a clinician, my last point would be very often, this translates into the coding of the severity of the illness and the adjustments that go into figuring out was this quality care or not. So, it goes way beyond the simple finances as important as…

Valerie: It does.

Dave: Great! Well, let’s wrap things up now and what I would ask you to do now is share with us your most sage advice.

Valerie: Okay. I’m happy to do that. So, I often tell people about an article that I read years ago, that I wish I would have kept. It was a study by Harvard and they had asked executives at a certain point in time how confident they were in the decisions they were making and the executives were 90% or better than this is the right decision. Years later they came back and they asked those same executives, okay, now what do you think about that decision you made and about 50% of them said, no, it wasn’t the right decision. So, don’t get too merit to a decision be looking to look at it objectively and tweak it along the way because retrospectively we’re gonna say only half the time did we really know we had the best of intensions when we made that decision, we were 90% confident but you know what, only half the time we were right. So, always be willing to go back and just scrutinize the decision. Just don’t get too merit to that decision.

Dave: Yes, so this is truly sage advice. Feels like it’s one of those things as executives and leaders. You can always work on improving decision making. Are there some specific tips or tricks or practices that you use? Can you help me with this?

Valerie: So, I think I was very lucky. I spent eight years working in the big four, primarily for Deloitte and I tell everybody, one of the things we were taught early on in our career was that our job was to blow holes in an idea before our client would. We didn’t want to go and look be embarrassed. So, don’t ever get defensive when somebody asks you a question or challenges you on an idea. So, I’ve always worked with my team is like, you’re not doing me any favors if you let me move forward with something and you’re not sharing complete knowledge. So, I really make sure my team knows that it’s a safe environment to present facts, to have a different opinion and to challenge each other. I don’t care if it is your boss, your peer, you co-worker, you have an obligation to challenge them and share information that you have. They may still choose to go ahead with that decision, they may alter it but making sure that you have a safe environment will people feel comfortable sharing is the most important thing that I do with my team.

Dave: And, that makes perfect sense to me. I’m a big believer in debate and that out of diversity and debate comes the best solution for that moment. None of us has a Zen lock on truth. The other thing that I find fascinating and I think this is Jeff Bezos who has talked about the idea of reversible and irreversible decisions and I think as much as possible where we can organize our work into a series of reversible decisions, it sets us up for that fail-fast cycle. So, get-in, fail, learn from that but you’re not locked in, you have a way to adjust them.

Valerie: Absolutely.

Dave: It’s having a healthy respect for the fact that most of the time we don’t know what we are doing and we don’t know what’s going on. So, we just got to go try it and figure out and see.

Valerie: Yeah. One of my favorite stories and it was while I was at Deloitte. I was a manager and it was another manager and we were definitely in disagreement on the next steps for our client and he had played college football. So, he was a big guy. He was getting pretty heated and we were getting back and forth debating and he paused, he goes, I just wanna make sure we’re okay. I said, oh yeah, we’re cool. I said, this is like a pick-up basketball game. We were just trying to get to the end result here and then he said, okay, I just wanna make sure we’re not getting mad at each other and we went back to a debate and at the end of the day I do think we put together a better recommendation for our client because we were both willing to challenge each other in our thinking, so…

Dave: Yeah, I’ve always said the secret there is to be hard on the problem and soft on the people.

Valerie: Exactly.

Dave: And so, I can poop all over your ideas, that’s fine but I shouldn’t attack you.

Valerie: Exactly, never make it personal.

Dave: Yeah, you know, it’s interesting that we at Sansoro Health, most of our staff is based in our Minneapolis office and there’s a thing called Minnesota Nice, maybe you’ve heard of that before and it’s interesting because we’ve had to rather directly address this at times as a group and say, it’s fine to be Minnesota Nice but you need to speak up when you disagree.

Valerie: Yeah, politically.

Dave: I think you’re more of a Southerner like I am. So, it’s sort of the equivalent when they say, well, just bless her heart and we all know, we know what they meant [Laugh]. Valerie, this has been terrific, thank you so much for your time today and for your sage advice. I’d like to give you the last word here.

Valerie: Okay well, I mean, thank you for having me. I really think if your listeners are out there, go back to your organization’s challenge and on what they are doing, push them to be thinking on the bleeding edge, the technology is getting ready to change fast and furious and you do not want to be left behind. So, like I tell everybody, just think critically about what you are doing and challenge your executives to push the revenue cycle and business processes forward, it will help everybody at the end of the day.

Dave: Valerie says get off the sideline and get in the game or you’re gonna be left behind, fantastic. We’ve been taking with Valerie Barckhoff, a principal in the Healthcare Consulting practice at Windham Brannon. Valerie, thanks so much for joining us today.

Valerie: Thank you, I appreciate it.

Dave: You’ve been listening to 4x4 Health, sponsored by Sansoro Health. Sansoro Health, integration at the speed of innovation. Check them out at www.sansorohealth.com. I hope you enjoy us next time for another 4x4 discussion with healthcare innovators. Until then, I’m your host Dr. Dave Levin, thanks for listening.