A design team relied on design principles and patient feedback to create an award-winning patient statement.
A team of designers at RadNet Inc., a large owner-operated network of imaging centers, participated in a national competition to create a patient-friendly medical billing statement. The team’s first place award in the “Easiest Bill to Understand” category demonstrates the value of going outside the patient financial services (PFS) department to develop financial communications—and it highlights the importance of good design to patient statements.
“So often when you look at medical bills, it’s just a sea of sameness with nothing to help the patient understand what’s most important,” says Randy Ziegler, RadNet’s director of web presence. “That is why bringing information design to a layout team can make the bill more understandable and accessible.”
The Challenge
The “A Bill You Can Understand” Design and Innovation Challenge, sponsored by AARP and administered by the Mad*Pow design agency, was an open design competition conducted in 2016 on behalf of the U.S. Department of Health & Human Services (HHS). The contest attracted 84 entries.
In addition to their own research, competitors used a report, prepared by Mad*Pow, that included many sample medical bills and insurance explanation-of-benefits (EOB) statements to give a broad perspective on how patient financial communications are presented. The report also included findings from a patient survey and interviews with healthcare executives and other stakeholders sharing their thoughts about the problems that plague medical bills.
See related sidebar: Top Patient Concerns About Medical Bills
Competitors were instructed to use “human-centered design,” which Mad*Pow described this way: an approach to creating solutions for problems and opportunities through a focus on the needs, contexts, behaviors, and emotions of the people that the solutions will serve.
“That represents a philosophical point of view that aligns with many of the folks in the design community,” Ziegler says.
Human-centered design is a concept more than a fixed set of steps, but it requires keeping the end user—in this case, the patient—front and center throughout the process, Ziegler says. That means incorporating patient feedback at every step.
“It’s this very iterative process that you engage in to improve and refine your thinking and problem-solving over time,” he says.
Ziegler and two RadNet colleagues—senior designer Daniel Pipitone and senior writer Mary O’Neill—had commiserated about the difficult-to-understand bills they had received for healthcare services. So, when the design challenge was announced, they seized the opportunity to undertake a learning exercise for themselves—and to help solve a problem that frustrates patients and providers throughout the industry.
“We realized that there’s so much room for improvement—and we have heard some of the challenges that our colleagues in payment operations face with collections,” he says. “We saw this as an opportunity to learn and begin to get our feet wet in this topic.”
RadNet’s payment operations leaders were enthusiastic about the process Ziegler’s team took and the design its team came up with. “It’s changing the way they think about the problem of medical bills and allowing them to envision some new opportunities they hadn’t thought about previously,” he says.
What Success Looks Like
The RadNet team developed distinct bill formats for three patient categories: a standard bill for patients with balances; payment-past-due bills; and bills for uninsured patients. Each format incorporates design principles to present information in a user-friendly manner.
Intention. The bill’s purpose, such as “This is a Past Due Bill,” is clearly and colorfully stated in the upper left corner. Information on how to receive help or contact the provider appears next to the intention statement.
Payment due: By using a consistent color and typography scheme on bills to express financial information, the design helps patients associate color and bold type with information about payments and amounts due.
- Payment status is presented at the top of summary pages and repeated on all detail pages.
- To keep bills concise, only new charges, combined adjustments, and payment due information is presented on the paper statement.
Past due amounts. All text related to past-due amounts is in red. This is a color cue designed to be “louder” in its message to the reader, Ziegler says.
Personalized messages. If patients are uninsured, a message next to the payment-due amount makes it clear that no insurance information is available and that the bill is final.
Payment options. Three options are presented on the top half of the statement, with complete instructions for each method:
- Pay online: The website and patients’ bill codes are listed.
- Pay by mail: The message reads, “Send your check along with the payment coupon below.”
- Pay by phone: The phone number is listed.
Payment coupon. Bills include coupons for paying by mail that include key information—amounts due, dates due, account numbers, and payment addresses—which serve as references even for those paying by phone or online.
Insurance summary. To help patients make connections between bills and their insurance coverage, an insurance snapshot includes the following elements:
- Patient health plan
- Patient policy number
- Policy renewal date
- Deductible limit
- Out-of-pocket paid toward deductible year-to-date
- Out-of-pocket paid toward copayment maximum year-to-date
- Current status, such as, “Your annual deductible has been met. Any out-of-pocket expenses are now covered, and you will only be responsible for any copayments.”
Charges. Each medical encounter is presented as its own self-contained “card” on the statement. The card information includes the following elements:
- Provider name and photograph (or facility name and photograph)
- Date of service
- Location of service
- Type of service (clearly written out with no codes)
- Financial service that includes amount that was billed, amount paid by insurance, amount patient needs to pay (highlighted in blue to stand out.)
Quick response (QR) jump-links. Paper bills provide only summary charge information. QR links allow patients to use smartphones to access an online portal to view details of each charge.
Frequently Asked Questions section. Each bill includes answers to the following questions:
- Why am I receiving this bill?
- Why is there a charge from a provider I don’t know?
- Why don’t I see my previous payments on my bill?
- Why is there no breakdown of charges on my bill?
RadNet Design Step-by-Step
The design challenge rules required the creation of a patient journey map that documents the steps patients experience as they interact with provider organizations. That is something that designers are trained to do, Ziegler says, because they must understand the nuanced experiences of users to design products that meet users’ needs.
The RadNet team had a real-life experience to draw from because Ziegler’s son had recently been through a frustrating two-week ordeal, including physician visits, imaging, laboratory work, and a three-day hospital stay, to get a diagnosis for Lyme disease.
“That was an excellent vehicle for us to capture the journey,” he says. “And the questions that we had when we looked at the medical bills we studied for the competition were actually my own questions when I looked at my son’s medical bills.”
From there, the following steps were taken.
A design audit. The team analyzed many medical billing and EOB statements to identify specific problems that made them difficult to understand.
Creation of “user profiles.” The team created four patient personas, assigning each of them a name, specific demographic characteristics, healthcare utilization patterns, and insurance status, to keep in mind as they made design decisions. “Just to make sure we weren’t thinking only about our own points of view, we would sometimes say, ‘What would Carol Anne think about this?’” he says, referring to one of the personas.
Initial designs, using a design concept called “wire-framing.” At this stage, the designers considered how to direct a reader’s attention to the most important elements on the bill in the order that information needs to be processed. “First, you need to understand this, and then you need to understand that,” Ziegler says.
This is where the team wrestled with exactly how much information should be included on the paper statement. During that process, three important decisions were made:
- Use a QR jump link that gives patients online access to details about the bill so that less information had to be presented on paper statements.
- Create variable bills for patients who owe balances, have past-due balances, or are uninsured, sending only an e-mail message to patients who owe nothing.
- Include information about the status of patients’ deductibles and copayments on every bill.
Iterative designs. Using decisions they made during the wire-framing stage, Ziegler and Pipitone worked independently to create a set of designs and invited colleagues to provide feedback.
“We put them all up on a board and had a good old-fashioned critique, just like design school, where people would say, ‘This doesn’t make sense to me,’ or, ‘I like this aspect,’” Ziegler says.
Synthesis and feedback. The designers used the feedback to identify the best ideas from each design and worked together to create a draft medical bill and online statement. They recruited family and friends—none of whom are in the healthcare industry—to review the drafts and provide feedback through a structured interview.
“We would ask them, ‘Can you tell me how much you owe for this service?’ or ‘Who performed this service?’ to test their ability to discover information they need to know,” he says. “And then we went broader and asked for their feedback about what was helpful, what was confusing.”
The feedback was incorporated to create the final designs that were submitted to—and took top honors in—the design challenge.
Working Together
Ziegler encourages PFS leaders to work with design professionals when changes to patient financial communications are being considered. “It’s not that design should be the driver; it should be collaborative,” he says. “The best outcomes here at RadNet come when design has a seat at the table.”
Lola Butcher is a freelance writer and editor based in Missouri, and a member of HFMA’s Show Me State of Missouri Chapter.
Interviewed for this article: Randy Ziegler is director of web presence, RadNet, Inc., Los Angeles.
